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Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients



Double level osteotomy (DLO) (femoral and tibial) is a technically demanding procedure for which pre-operative planning accuracy and intraoperative correction are key factors. The aim of this study was to assess the accuracy of the achieved correction using patient-specific cutting guides (PSCGs) compared to the planned correction, its ability to maintain joint line obliquity (JLO), and to evaluate clinical outcomes and level of patient satisfaction at a follow-up of two years.


A single-centre, prospective observational study including 22 patients who underwent DLO by PSCGs between 2014 and 2018 was performed. Post-operative alignment was evaluated and compared with the target angular values to define the accuracy of the correction for the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), lateral distal femoral angle (ΔLDFA), and posterior proximal tibial angle (ΔPPTA). Pre- and post-operative JLO was also evaluated. At two year follow-up, changes in the KOOS sub-scores and patient satisfaction were recorded. The Mann–Whitney U test with 95% confidence interval (95% CI) was used to evaluate the differences between two variables; the paired Student’s t test was used to estimate evolution of functional outcomes.


The mean ΔHKA was 1.3 ± 0.5°; the mean ΔMPTA was 0.98 ± 0.3°; the mean ΔLDFA was 0.94 ± 0.2°; ΔPPTA was 0.45 ± 0.4°. The orientation of the joint line was preserved with a mean difference in the JLO of 0.4 ± 0.2. At last follow-up, it was recorded a significant improvement in all KOOS scores, and 19 patients were enthusiastic, two satisfied, and one moderately satisfied.


Performing a DLO using PSCGs produces an accurate correction, without modification of the joint line orientation and with good functional outcomes at two year follow-up

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  1. Conventry MB (2001) Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report by Mark B. Conventry, MD. From the Section of Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. 1965. J Bone Joint Surg Am 83:1426

  2. 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  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  4. Seil R, van Heerwaarden R, Lobenhoffer P, Kohn D (2013) The rapid evolution of knee osteotomies. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 21:1–2.

    Article  Google Scholar 

  5. Saragaglia D, Chedal-Bornu B, Rouchy RC et al (2016) Role of computer-assisted surgery in osteotomies around the knee. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 24:3387–3395.

    CAS  Article  Google Scholar 

  6. Sharma L, Song J, Felson DT et al (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA 286:188–195.

    CAS  Article  PubMed  Google Scholar 

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

  8. Sailhan F, Jacob L, Hamadouche M (2017) Differences in limb alignment and femoral mechanical-anatomical angles using two dimension versus three dimension radiographic imaging. Int Orthop 41:2009–2016.

    Article  PubMed  Google Scholar 

  9. Donnez M, Ollivier M, Munier M et al (2018) Are three-dimensional patient-specific cutting guides for open wedge high tibial osteotomy accurate? An in vitro study. J Orthop Surg 13:171.

    Article  Google Scholar 

  10. Ke S, Ran T, He Y et al (2020) Does patient-specific instrumentation increase the risk of notching in the anterior femoral cortex in total knee arthroplasty? A comparative prospective trial. Int Orthop 44:2603–2611.

    Article  PubMed  Google Scholar 

  11. Thienpont E, Schwab PE, Fennema P (2014) A systematic review and meta-analysis of patient-specific instrumentation for improving alignment of the components in total knee replacement. Bone Jt J 96-B:1052–1061.

  12. Haglin JM, Eltorai AEM, Gil JA et al (2016) Patient-specific orthopaedic implants. Orthop Surg 8:417–424.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Jacquet C, Sharma A, Fabre M et al (2019) Patient-specific high-tibial osteotomy’s “cutting-guides” decrease operating time and the number of fluoroscopic images taken after a Brief Learning Curve. Knee Surg Sports Traumatol Arthrosc Off J ESSKA.

    Article  Google Scholar 

  14. Jacquet C, Chan-Yu-Kin J, Sharma A et al (2019) "More accurate correction using “patient-specific” cutting guides in opening wedge distal femur varization osteotomies. Int Orthop 43:2285–2291.

    Article  PubMed  Google Scholar 

  15. Chaouche S, Jacquet C, Fabre-Aubrespy M et al (2019) Patient-specific cutting guides for open-wedge high tibial osteotomy: safety and accuracy analysis of a hundred patients continuous cohort. Int Orthop 43:2757–2765.

    Article  PubMed  Google Scholar 

  16. Gómez-Palomo JM, Meschian-Coretti S, Esteban-Castillo JL et al (2020) Double level osteotomy assisted by 3D printing technology in a patient with blount disease: a case report. JBJS Case Connect 10:e0477.

    Article  PubMed  Google Scholar 

  17. Munier M, Donnez M, Ollivier M et al (2017) Can three-dimensional patient-specific cutting guides be used to achieve optimal correction for high tibial osteotomy? Pilot study. Orthop Traumatol Surg Res OTSR 103:245–250.

    CAS  Article  PubMed  Google Scholar 

  18. Dijkman BG, Sprague S, Schemitsch EH, Bhandari M (2010) When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma 24(Suppl 1):S76-80.

    Article  PubMed  Google Scholar 

  19. Benjamin A (1969) Double osteotomy for the painful knee in rheumatoid arthritis and osteoarthritis. J Bone Joint Surg Br 51:694–699

    CAS  Article  Google Scholar 

  20. Babis GC, An K-N, Chao EYS et al (2002) Double level osteotomy of the knee: a method to retain joint-line obliquity. Clinical results. J Bone Joint Surg Am 84:1380–1388.

    Article  PubMed  Google Scholar 

  21. Saragaglia D, Roberts J (2005) Navigated osteotomies around the knee in 170 patients with osteoarthritis secondary to genu varum. Orthopedics 28:s1269-1274

    Article  Google Scholar 

  22. Maurer F, Wassmer G (2006) High tibial osteotomy: does navigation improve results? Orthopedics 29:S130-132

    PubMed  Google Scholar 

  23. Saragaglia D, Blaysat M, Mercier N, Grimaldi M (2012) Results of forty two computer-assisted double level osteotomies for severe genu varum deformity. Int Orthop 36:999–1003.

    Article  PubMed  Google Scholar 

  24. Lee D-H, Park S-C, Park H-J, Han S-B (2016) Effect of soft tissue laxity of the knee joint on limb alignment correction in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 24:3704–3712.

    Article  Google Scholar 

  25. Predescu V, Grosu A-M, Gherman I et al (2021) Early experience using patient-specific instrumentation in opening wedge high tibial osteotomy. Int Orthop.

    Article  PubMed  Google Scholar 

  26. Pérez-Mañanes R, Burró JA, Manaute JR et al (2016) 3D surgical printing cutting guides for open-wedge high tibial osteotomy: do it yourself. J Knee Surg 29:690–695.

    Article  PubMed  Google Scholar 

  27. Cerciello S, Ollivier M, Corona K et al (2020) CAS and PSI increase coronal alignment accuracy and reduce outliers when compared to traditional technique of medial open wedge high tibial osteotomy: a meta-analysis. Knee Surg Sports Traumatol Arthrosc Off J ESSKA.

    Article  Google Scholar 

  28. Schröter S, Nakayama H, Yoshiya S et al (2019) Development of the double level osteotomy in severe varus osteoarthritis showed good outcome by preventing oblique joint line. Arch Orthop Trauma Surg 139:519–527.

    Article  PubMed  Google Scholar 

  29. Micicoi G, Grasso F, Kley K, et al (2021) Osteotomy around the knee is planned toward an anatomical bone correction in less than half of patients. Orthop Traumatol Surg Res OTSR 102897.

  30. Nakayama H, Schröter S, Yamamoto C et al (2018) Large correction in opening wedge high tibial osteotomy with resultant joint-line obliquity induces excessive shear stress on the articular cartilage. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 26:1873–1878.

    Article  Google Scholar 

  31. Akamatsu Y, Nejima S, Tsuji M et al (2021) Joint line obliquity was maintained after double-level osteotomy, but was increased after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc Off J ESSKA.

    Article  Google Scholar 

  32. Song J-H, Bin S-I, Kim J-M, Lee B-S (2020) What is an acceptable limit of joint-line obliquity after medial open wedge high tibial osteotomy? Analysis based on midterm results. Am J Sports Med 48:3028–3035.

    Article  PubMed  Google Scholar 

  33. Nakayama H, Iseki T, Kanto R et al (2020) Physiologic knee joint alignment and orientation can be restored by the minimally invasive double level osteotomy for osteoarthritic knees with severe varus deformity. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 28:742–750.

    Article  Google Scholar 

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Authors and Affiliations



MO, LH, and CJ designed the protocol. MO, LH, and KK gathered the patients’ data anonymously. FG, KK, and RK performed database analysis. CJ, MO, and FG wrote the initial draft. MO, CJ, FG, KK, RK, GM, and PM edited the different version of the draft. MO, CJ, FG, KK, RK, LH, GM, and PM approved the submitted and final versions.

Corresponding author

Correspondence to Matthieu Ollivier.

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Ethics approval and consent to participate and to publish

Patient consent was collected pre-operatively after they were informed of the procedure in accordance with the principles of the Declaration of Helsinki. Local Ethical Committee approval was obtained prior to study’s initiation (Comité Informatique et Liberté (CIL)/Assistance Publique des Hopitaux de Marseille (AP-HM)/Registration Number 2019–127)).

Conflict of interest

MO is educational consultant for New-Clip, Stryker, and Arthrex. KK is educational consultant for New-Clip. CJ, RK, FG, PM, GM, and LH have no relevant financial or non-financial interests to disclose.

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Grasso, F., Martz, P., Micicoi, G. et al. Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients. International Orthopaedics (SICOT) 46, 473–479 (2022).

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  • Double level osteotomy
  • Patient-specific cutting guide
  • Accuracy
  • Joint line obliquity
  • Clinical outcomes