Tibiofemoral Malalignment

  • Andreas H. GomollEmail author


Osteotomy is one of the oldest surgical techniques for the treatment of knee osteoarthritis. After years of lagging interest due to the introduction and success of total knee arthroplasty, it has recently seen renewed attention. The increased frequency of sports-related injuries, especially anterior cruciate ligament (ACL) tears with their high rate of associated meniscal injury, has led to an increased incidence of cartilage damage in ever younger age groups, while older age groups with osteoarthritis wish to remain active later in life (age defying “baby boomers”) than previous generations and also want to avoid the restrictions associated with arthroplasty. Today, osteotomy plays a role in the treatment of physiologically young patients with symptomatic unicompartmental cartilage damage, ranging from focal chondral defects to osteoarthritis. It also has become an important adjunct to cartilage repair and other soft tissue procedures, such as meniscus transplantation and ligament reconstruction.


Proximal tibial valgus osteotomy Distal femoral varus osteotomy 


  1. 1.
    Buckwalter JA, Martin JA, Brown TD. Perspectives on chondrocyte mechanobiology and osteoarthritis. Biorheology. 2006;43(3–4):603–9.PubMedGoogle Scholar
  2. 2.
    van Dijk CN, Lim LS, Poortman A, Strubbe EH, Marti RK. Degenerative joint disease in female ballet dancers. Am J Sport Med. 1995;23(3):295–300.CrossRefGoogle Scholar
  3. 3.
    Buckwalter JA, Mankin HJ, Grodzinsky AJ. Articular cartilage and osteoarthritis. Instr Course Lect. 2005;54:465–80.PubMedGoogle Scholar
  4. 4.
    Paley D, Pfeil J. Principles of deformity correction around the knee. Orthopade. 2000;29(1):18–38.PubMedGoogle Scholar
  5. 5.
    Andriacchi TP. Dynamics of knee malalignment. Orthop Clin North Am. 1994;25(3):395–403.PubMedGoogle Scholar
  6. 6.
    Mina C, Garrett WE Jr, Pietrobon R, Glisson R, Higgins L. High tibial osteotomy for un-loading osteochondral defects in the medial compartment of the knee. Am J Sports Med. 2008;36(5):949–55.CrossRefPubMedGoogle Scholar
  7. 7.
    Shelburne KB, Torry MR, Pandy MG. Contributions of muscles, ligaments, and the ground-reaction force to tibiofemoral joint loading during normal gait. J Orthop Res. 2006;24(10):1983–90.CrossRefPubMedGoogle Scholar
  8. 8.
    Taylor WR, Heller MO, Bergmann G, Duda GN. Tibio-femoral loading during human gait and stair climbing. J Orthop Res. 2004;22(3):625–32.CrossRefPubMedGoogle Scholar
  9. 9.
    Guettler J, Glisson R, Stubbs A, Jurist K, Higgins L. The triad of varus malalignment, meniscectomy, and chondral damage: a biomechanical explanation for joint degeneration. Orthopedics. 2007;30(7):558–66.PubMedGoogle Scholar
  10. 10.
    Tetsworth K, Malalignment PD. Degenerative arthropathy. Orthop Clin North Am. 1994;25(3):367–77.PubMedGoogle Scholar
  11. 11.
    Brouwer GM, van Tol AW, Bergink AP, et al. Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum. 2007;56(4):1204–11.CrossRefPubMedGoogle Scholar
  12. 12.
    Cerejo R, Dunlop DD, Cahue S, Channin D, Song J, Sharma L. The influence of align-ment on risk of knee osteoarthritis progression according to baseline stage of disease. Arthritis Rheum. 2002;46(10):2632–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at base-line can predict radiographic disease progression in medial compartment knee osteoarthritis. Ann Rheum Dis. 2002;61(7):617–22.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA. 2001;286(2):188–95.CrossRefPubMedGoogle Scholar
  15. 15.
    Cicuttini F, Wluka A, Hankin J, Wang Y. Longitudinal study of the relationship between knee angle and tibiofemoral cartilage volume in subjects with knee osteoarthritis. Rheumatology (Oxford). 2004;43(3):321–4.CrossRefGoogle Scholar
  16. 16.
    Felson DT, Gale DR, Elon Gale M, et al. Osteophytes and progression of knee osteoarthritis. Rheumatology (Oxford). 2005;44(1):100–4.CrossRefGoogle Scholar
  17. 17.
    Tanamas S, Hanna FS, Cicuttini FM, Wluka AE, Berry P, Urquhart DM. Does knee malalignment increase the risk of development and progression of knee osteoarthritis? A systematic review. Arthritis Rheum. 2009;61(4):459–67.CrossRefPubMedGoogle Scholar
  18. 18.
    Neogi T, Felson D, Niu J, et al. Cartilage loss occurs in the same subregions as subchondral bone attrition: a within-knee subregion-matched approach from the multicenter Osteo-arthritis study. Arthritis Rheum. 2009;61(11):1539–44.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Neogi T, Nevitt M, Niu J, et al. Subchondral bone attrition may be a reflection of com-partment-specific mechanical load: the MOST study. Ann Rheum Dis. 2010;69(5):841–4.CrossRefPubMedGoogle Scholar
  20. 20.
    Hunter DJ, Zhang Y, Niu J, et al. Structural factors associated with malalignment in knee osteoarthritis: the Boston osteoarthritis knee study. J Rheumatol. 2005;32(11):2192–9.PubMedGoogle Scholar
  21. 21.
    Wakabayashi S, Akizuki S, Takizawa T, Yasukawa YA. Comparison of the healing po-tential of fibrillated cartilage versus eburnated bone in osteoarthritic knees after high tibial osteotomy: an arthroscopic study with 1-year follow-up. Arthroscopy. 2002;18(3):272–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Kanamiya T, Naito M, Hara M, Yoshimura I. The influences of biomechanical factors on cartilage regeneration after high tibial osteotomy for knees with medial compartment osteo-arthritis. clinical and arthroscopic observations Arthroscopy. 2002;18(7):725–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am. 1979;10(3):585–608.PubMedGoogle Scholar
  24. 24.
    Akizuki S, Yasukawa Y, Takizawa T. Does arthroscopic abrasion arthroplasty promote cartilage regeneration in osteoarthritic knees with eburnation? A prospective study of high tibial osteotomy with abrasion arthroplasty versus high tibial osteotomy alone. Arthroscopy. 1997;13(1):9–17.CrossRefPubMedGoogle Scholar
  25. 25.
    Koshino T, Wada S, Ara Y, Saito T. Regeneration of degenerated articular cartilage after high tibial valgus osteotomy for medial compartmental osteoarthritis of the knee. Knee. 2003;10(3):229–36.CrossRefPubMedGoogle Scholar
  26. 26.
    Parker DA, Beatty KT, Giuffre B, Scholes CJ, Coolican MR. Articular cartilage changes in patients with osteoarthritis after osteotomy. Am J Sports Med. 2011;39(5):1039–45.CrossRefPubMedGoogle Scholar
  27. 27.
    Van Thiel GS, Frank RM, Gupta A, et al. Biomechanical evaluation of a high tibial osteotomy with a meniscal transplant. J Knee Surg. 2011;24(1):45–53.CrossRefPubMedGoogle Scholar
  28. 28.
    Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13(4):279–89.CrossRefPubMedGoogle Scholar
  29. 29.
    Badhe NP, Forster IW. High tibial osteotomy in knee instability: the rationale of treat-ment and early results. Knee Surg Sports Traumatol Arthrosc. 2002;10(1):38–43.CrossRefPubMedGoogle Scholar
  30. 30.
    Naudie DD, Amendola A, Fowler PJ. Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med. 2004;32(1):60–70.CrossRefPubMedGoogle Scholar
  31. 31.
    Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28(3):282–96.CrossRefPubMedGoogle Scholar
  32. 32.
    Majima T, Yasuda K, Aoki Y, Minami A. Impact of patellofemoral osteoarthritis on long-term outcome of high tibial osteotomy and effects of ventralization of tibial tubercle. J Orthop Sci. 2008;13(3):192–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Kang SN, Smith TO, De Rover WB, Walton NP. Pre-operative patellofemoral degenerative changes do not affect the outcome after medial Oxford unicompartmental knee re-placement: a report from an independent Centre. J Bone Joint Surg Br. 2011;93(4):476–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Zarrouk A, Bouzidi R, Karray B, Kammoun S, Mourali S, Kooli M. Distal femoral varus osteotomy outcome: is associated femoropatellar osteoarthritis consequential? Orthop Traumatol Surg Res. 2010;96(6):632–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Brinkman JM, Lobenhoffer P, Agneskirchner JD, Staubli AE, Wymenga AB, van Heerwaarden RJ. Osteotomies around the knee: patient selection, stability of fixation and bone healing in high tibial osteotomies. J Bone Joint Surg Br. 2008;90(12):1548–57.CrossRefPubMedGoogle Scholar
  36. 36.
    Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639–46.CrossRefPubMedGoogle Scholar
  37. 37.
    Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP. Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function. Am J Sports Med. 2006;34(8):1262–73.CrossRefPubMedGoogle Scholar
  38. 38.
    Spahn G. Complications in high tibial (medial opening wedge) osteotomy. Arch Orthop Trauma Surg. 2004;124(10):649–53.CrossRefPubMedGoogle Scholar
  39. 39.
    Spahn G, Kirschbaum S, Kahl E. Factors that influence high tibial osteotomy results in patients with medial gonarthritis: a score to predict the results. Osteoarthr Cartil. 2006;14(2):190–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Brouwer RW, van TM R, Bierma-Zeinstra SM, Verhagen AP, Jakma TS, Verhaar JA. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. 2007;3:CD00401–9.Google Scholar
  41. 41.
    Coventry MB. Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report J Bone Joint Surg Am. 1965;47:984–90.CrossRefPubMedGoogle Scholar
  42. 42.
    Insall JN, Joseph DM, Msika C. High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am. 1984;66(7):1040–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Sah AP, Scott RD. Lateral unicompartmental knee arthroplasty through a medial approach. Surgical technique. J Bone Joint Surg Am. 2008;90(Suppl 2, Pt 2):195–205.CrossRefPubMedGoogle Scholar
  44. 44.
    Chambat P, Selmi TA, DeJour D, Denoyers J. Varus tibial osteotomy. Oper Tech Sports Med. 2000;8:44–7.CrossRefGoogle Scholar
  45. 45.
    Healy WL, Anglen JO, Wasilewski SA, Krackow KA. Distal femoral varus osteotomy. J Bone Joint Surg. 1988;70(1):102–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Marti RK, Verhagen RA, Kerkhoffs GM, Moojen TM. Proximal tibial varus osteotomy. Indications, technique, and five to twenty-one-year results. J Bone Joint Surg Am. 2001;83(2):164–70.CrossRefPubMedGoogle Scholar
  47. 47.
    Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am. 1987;69(3):332–54.CrossRefPubMedGoogle Scholar
  48. 48.
    Poignard A, Flouzat Lachaniette CH, Amzallag J, Hernigou P. Revisiting high tibial osteotomy: fifty years of experience with the opening-wedge technique. J Bone Joint Surg. 2010;92(Suppl 2):187–95.CrossRefPubMedGoogle Scholar
  49. 49.
    Giffin JR, Shannon FJ. The role of the high tibial osteotomy in the unstable knee. Sports Med Arthrosc Rev. 2007;15(1):23–31.CrossRefPubMedGoogle Scholar
  50. 50.
    Savarese E, Bisicchia S, Romeo R, Amendola A. Role of high tibial osteotomy in chronic injuries of posterior cruciate ligament and posterolateral corner. J Orthop Traumatol. 2011;12(1):1–17.CrossRefPubMedGoogle Scholar
  51. 51.
    Puddu G, Cipolla M, Cerullo G, Franco V, Gianni E. Which osteotomy for a valgus knee? Int Orthop. 2010;34(2):239–47.CrossRefPubMedGoogle Scholar
  52. 52.
    Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am. 1993;75(2):196–201.CrossRefPubMedGoogle Scholar
  53. 53.
    Tang WC, Henderson IJ. High tibial osteotomy: long term survival analysis and patients’ perspective. Knee. 2005;12(6):410–3.CrossRefPubMedGoogle Scholar
  54. 54.
    Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The install award. Survivorship of the high tibial valgus osteotomy. A 10 to 22-year followup study. Clin Orthop Relat Res. 1999;367:18–27.CrossRefGoogle Scholar
  55. 55.
    Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival and failure analysis to twenty-two years. J Bone Joint Surg Am. 2003;85(3):469–74.CrossRefPubMedGoogle Scholar
  56. 56.
    Efe T, Ahmed G, Heyse TJ, et al. Closing-wedge high tibial osteotomy: survival and risk factor analysis at long-term follow up. BMC Musculoskelet Disord. 2011;12:46.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Polat G, Balci HI, Cakmak MF, et al. Long-term results and comparison of the three different high tibial osteotomy and fixation techniques in medial compartment arthrosis. J Orthop Surg Res. 2017;12(1):44.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Bode GJ, von Heyden J, Pestka H, et al. Prospective 5-year survival rate data following open-wedge valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):1949–55.CrossRefPubMedGoogle Scholar
  59. 59.
    Hui C, Salmon LJ, Kok A, et al. Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee. Am J Sports Med. 2011;39(1):64–70.CrossRefPubMedGoogle Scholar
  60. 60.
    Schallberger A, Jacobi M, Wahl P, et al. High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13-21 years. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):122–7.CrossRefPubMedGoogle Scholar
  61. 61.
    Asik M, Sen C, Kilic B, Goksan SB, Ciftci F, Taser OF. High tibial osteotomy with Pud-du plate for the treatment of varus gonarthrosis. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):948–54.CrossRefPubMedGoogle Scholar
  62. 62.
    Gstottner M, Pedross F, Liebensteiner M, Bach C. Long-term outcome after high tibial osteotomy. Arch Orthop Trauma Surg. 2008;128(1):111–5.PubMedGoogle Scholar
  63. 63.
    Saragaglia D, Blaysat M, Inman D, Mercier N. Outcome of opening wedge high tibial osteotomy augmented with a biosorb(R) wedge and fixed with a plate and screws in 124 pa-tients with a mean of ten years follow-up. Int Orthop. 2011;35(8):1151–6.CrossRefPubMedGoogle Scholar
  64. 64.
    Yan J, Musahl V, Kay J, Khan M, et al. Outcome reporting following navigated high tibial osteotomy of the knee: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24(11):3529–55.CrossRefPubMedGoogle Scholar
  65. 65.
    Smith TO, Sexton D, Mitchell P, Hing CB. Opening- or closing-wedged high tibial osteotomy: a meta-analysis of clinical and radiological outcomes. Knee. 2011;18(6):361–8.CrossRefPubMedGoogle Scholar
  66. 66.
    Song EK, Seon JK, Park SJ, Jeong MS. The complications of high tibial osteotomy: closing- versus opening-wedge methods. J Bone Joint Surg Br. 2010;92(9):1245–52.CrossRefPubMedGoogle Scholar
  67. 67.
    Brouwer RW, Bierma-Zeinstra SM, van Raaij TM, Verhaar JA. Osteotomy for medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled by a Puddu plate. A one-year randomised, controlled study. J Bone Joint Surg Br. 2006;88(11):1454–9.CrossRefPubMedGoogle Scholar
  68. 68.
    Rinonapoli E, Mancini GB, Corvaglia A, Musiello S. Tibial osteotomy for varus gonarthrosis. A 10- to 21-year followup study. Clin Orthop Relat Res. 1998;353:185–93.CrossRefGoogle Scholar
  69. 69.
    Salzmann GM, Ahrens P, Naal FD, et al. Sporting activity after high tibial osteotomy for the treatment of medial compartment knee osteoarthritis. Am J Sports Med. 2009;37(2):312–8.CrossRefPubMedGoogle Scholar
  70. 70.
    Ihle C, Ateschrang A, Grunwald L, et al. Health-related quality of life and clinical outcomes following medial open wedge high tibial osteotomy: a prospective study. BMC Musculoskelet Disord. 2016;17:215.CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Odenbring S, Egund N, Lindstrand A, Lohmander LS, Willen H. Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis. An arthroscopic, roentgenographic, and histologic study. Clin Orthop Relat Res. 1992;277:210–6.Google Scholar
  72. 72.
    McDermott AG, Finklestein JA, Farine I, Boynton EL, MacIntosh DL, Gross A. Distal femoral varus osteotomy for valgus deformity of the knee. J Bone Joint Surg Am. 1988;70(1):110–6.CrossRefPubMedGoogle Scholar
  73. 73.
    Terry GC, Cimino PM. Distal femoral osteotomy for valgus deformity of the knee. Orthopedics. 1992;15(11):1283–9. (discussion 1289–90)PubMedGoogle Scholar
  74. 74.
    Edgerton BC, Mariani EM, Morrey BF. Distal femoral varus osteotomy for painful genu valgum. A five-to-11-year follow-up study. Clin Orthop Relat Res. 1993;288:263–9.Google Scholar
  75. 75.
    Wang JW, Hsu CC. Distal femoral varus osteotomy for osteoarthritis of the knee. J Bone Joint Surg Am. 2005;87(1):127–33.CrossRefPubMedGoogle Scholar
  76. 76.
    Finkelstein JA, Gross AE, Davis A. Varus osteotomy of the distal part of the femur. A survivorship analysis. J Bone Joint Surg Am. 1996;78(9):1348–52.CrossRefPubMedGoogle Scholar
  77. 77.
    Kosashvili Y, Safir O, Gross A, Morag G, Lakstein D, Backstein D. Distal femoral varus osteotomy for lateral osteoarthritis of the knee: a minimum ten-year follow-up. Int Orthop. 2010;34(2):249–54.CrossRefPubMedGoogle Scholar
  78. 78.
    Backstein D, Morag G, Hanna S, Safir O, Gross A. Long-term follow-up of distal femoral varus osteotomy of the knee. J Arthroplast. 2007;22(4 Suppl 1):2–6.CrossRefGoogle Scholar
  79. 79.
    Wylie JD, Jones DL, Hartley MK, et al. Distal femoral osteotomy for the valgus knee: medial closing wedge versus lateral opening wedge: a systematic review. Arthroscopy. 2016;32(10):2141–7.CrossRefPubMedGoogle Scholar
  80. 80.
    Chahla J, Mitchell JJ, Liechti DJ, et al. Opening- and closing-wedge distal femoral osteotomy: a systematic review of out-comes for isolated lateral compartment osteoarthritis. Orthop J Sports Med. 2016;4(6):2325967116649901.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Sternheim A, Garbedian S, Backstein D. Distal femoral varus osteotomy: unloading the lateral compartment: long-term follow-up of 45 medial closing wedge osteotomies. Orthopedics. 2011;34(9):e488–90.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryHospital for Special SurgeryNew YorkUSA

Personalised recommendations