The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Impact of the Opening-Wedge and Closing-Wedge High Tibial Osteotomy on Clinical Outcomes of Total Knee Arthroplasty: A Systematic Review of Comparative Clinical Studies

Document Type : SYSTEMATIC REVIEW

Authors
Mohammad Amin Khojastehnezhad 1
Mohammad H. Ebrahimzadeh 1
Mohsen Dehghani 2
Maedeh Sharafoddin 1
Ali Moradi 1
Fatemeh Nikbakht 3
Nafiseh Jirofti 1
1 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2 Department of Epidemiology, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
3 Torbat Jam Faculty of Medical Sciences, Torbat Jam, Iran
10.22038/abjs.2026.95154.4275
Abstract
Objectives: Eventually, both closing-wedge high tibial osteotomy (CW-HTO) and opening-wedge high tibial osteotomy (OW-HTO) may fail, necessitating conversion to total knee arthroplasty (TKA), one of the most successful procedures in orthopedic surgery. This systematic review aimed to answer the following question: What are the clinical and surgical outcomes of TKA after CW-HTO and OW-HTO?
Methods: The main electronic databases were searched up to November 2025. Only studies that included comparative arms for both closing-wedge high tibial osteotomy (CW-HTO) and opening-wedge high tibial osteotomy (OW-HTO) were considered for further assessment. The primary outcomes included knee joint function scores, such as the International Knee Society (IKS) score and the Knee Society Score (KSS). A meta-analysis was not feasible because of heterogeneity in the reported data and follow-up periods. The Joanna Briggs Institute (JBI) critical appraisal tool was used to assess the methodological quality of each included study.
Results: Of the 6,756 records identified and screened, three comparative clinical studies, including a total of 541 TKA cases, were included in this systematic review. Two studies reported no significant difference in KSS or range of motion after TKA between patients who had previously undergone CW-HTO and those who had undergone OW-HTO. However, one study reported improvements in walking ability in both groups after 80–90 months of follow-up. The most frequently reported complications were skin necrosis, joint stiffness, infection, peroneal nerve injury, and posterior tibial nerve injury.
Conclusion: The limited available evidence precludes definitive conclusions. Current data suggest potential benefits after TKA following either CW-HTO or OW-HTO, including earlier relief of joint loading, shorter recovery time, and improved clinical outcomes, with no significant differences between the two HTO techniques.
Level of evidence: V
Keywords
Closing wedge high tibial osteotomy
Knee osteoarthritis
Opening wedge high tibial osteotomy
Systematic review
Total knee arthroplasty
Subjects
  1. Perruccio AV, Young JJ, Wilfong JM, Power JD, Canizares M, Badley EM. Osteoarthritis year in review 2023: Epidemiology & therapy. Osteoarthritis Cartilage. 2024;32(2):159-165. doi: 10.1016/j.joca.2023.11.012.
  2. Courties A, Kouki I, Soliman N, Mathieu S, Sellam J. Osteoarthritis year in review 2024: Epidemiology and therapy. Osteoarthritis Cartilage. 2024;32(11):1397-1404. doi: 10.1016/j.joca.2024.07.014.
  3. Leichtenberg CS, van Tol FR, Gademan MGJ, et al. Are pain, functional limitations and quality of life associated with objectively measured physical activity in patients with end-stage osteoarthritis of the hip or knee? Knee. 2021;29:78-85. doi:10.1016/j.knee.2020.12.019.
  4. Siren J, Rämö L, Rantasalo M, et al. Unicompartmental knee arthroplasty vs. high tibial osteotomy for medial knee osteoarthritis (UNIKORN): a study protocol of a randomized controlled trial. Trials. 2023;24(1):256. doi:10.1186/s13063-023-07263-7.
  5. Puddu G, Cerullo G, Cipolla M, Franco V, Giannì E, Panarella L. Technique and Outcomes of Opening Wedge High Tibial Osteotomy. Seminars in Arthroplasty. 2007;18(2):148-155. doi:10.1053/j.sart.2007.03.004.
  6. 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. doi: 10.1177/0363546510377445.
  7. Safdari M, Dastjerdi A, Makhmalbaf N, Makhmalbaf M, Makhmalbaf H. Closing-Wedge and Opening-Wedge High Tibial Osteotomy as Successful Treatments of ‎Symptomatic Medial Osteoarthritis of the Knee: A Randomized Controlled Trial. Arch Bone Jt Surg. 2023;11(6):421-428. doi:10.22038/abjs.2023.68944.3253.
  8. Duivenvoorden T, van Diggele P, Reijman M, et al. Adverse events and survival after closing- and opening-wedge high tibial osteotomy: a comparative study of 412 patients. Knee Surg Sports Traumatol Arthrosc. 2017;25(3):895-901. doi:10.1007/s00167-015-3644-2.
  9. Luites JW, Brinkman JM, Wymenga AB, van Heerwaarden RJ. Fixation stability of opening- versus closing-wedge high tibial osteotomy: a randomised clinical trial using radiostereometry. J Bone Joint Surg Br. 2009;91(11):1459-65. doi:10.1302/0301-620x.91b11.22614.
  10. van Raaij TM, Bakker W, Reijman M, Verhaar JA. The effect of high tibial osteotomy on the results of total knee arthroplasty: a matched case control study. BMC Musculoskelet Disord. 2007:8:74. doi: 10.1186/1471-2474-8-74.
  11. Spahn G, Hofmann GO, von Engelhardt LV, Li M, Neubauer H, Klinger HM. The impact of a high tibial valgus osteotomy and unicondylar medial arthroplasty on the treatment for knee osteoarthritis: a meta-analysis. Knee Surg Sports Traumatol Arthrosc.2013;21(1):96-112. doi: 10.1007/s00167-011-1751-2.
  12. Primeau CA, Birmingham TB, Leitch KM, et al. Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors. CMAJ. 2021;193(5):E158-E166. doi: 10.1503/cmaj.200934.
  13. Keenan O, Clement N, Nutton R, Keating J. Older age and female gender are independent predictors of early conversion to total knee arthroplasty after high tibial osteotomy. Knee.2019;26(1):207-212. doi: 10.1016/j.knee.2018.11.008.
  14. Carr AJ, Robertsson O, Graves S, et al. Knee replacement. Lancet.2012;379(9823):1331-40. doi: 10.1016/S0140-6736(11)60752-6.
  15. Steinhaus ME, Christ AB, Cross MB. Total Knee Arthroplasty for Knee Osteoarthritis: Support for a Foregone Conclusion? HSS J. 2017;13(2):207-210. doi: 10.1007/s11420-017-9558-4.
  16. Han JH, Yang JH, Bhandare NN, et al. Total knee arthroplasty after failed high tibial osteotomy: a systematic review of open versus closed wedge osteotomy. Knee Surg Sports Traumatol Arthrosc.2016;24(8):2567-77. doi: 10.1007/s00167-015-3807-1.
  17. Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation

 

        and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ.2021:372:n160. doi: 10.1136/bmj.n160.

  1. Munn Z, Barker TH, Moola S, et al. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth.2020;18(10):2127-2133. doi: 10.11124/JBISRIR-D-19-00099.
  2. Bastos Filho R, Magnussen RA, Duthon V, et al. Total knee arthroplasty after high tibial osteotomy: a comparison of opening and closing wedge osteotomy. Int Orthop. 2013;37(3):427-31. doi:10.1007/s00264-012-1765-5.
  3. Ehlinger M, D'Ambrosio A, Vie P, et al. Total knee arthroplasty after opening- versus closing-wedge high tibial osteotomy. A 135-case series with minimum 5-year follow-up. Orthop Traumatol Surg Res. 2017;103(7):1035-1039. doi:10.1016/j.otsr.2017.07.011.
  4. Preston S, Howard J, Naudie D, Somerville L, McAuley J. Total knee arthroplasty after high tibial osteotomy: no differences between medial and lateral osteotomy approaches. Clin Orthop Relat Res. 2014;472(1):105-10. doi:10.1007/s11999-013-3040-5.
  5. Barker TH, Stone JC, Sears K, et al. Revising the JBI quantitative critical appraisal tools to improve their applicability: an overview of methods and the development process. JBI Evid Synth. 2023;21(3):478-493. doi: 10.11124/JBIES-22-00125.
  6. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-30. doi:10.1136/annrheumdis-2013-204763.
  7. Fowler PJ, Tan JL, Brown GA. Medial Opening Wedge High Tibial Osteotomy: How I Do It. Operative Techniques in Sports Medicine. 2012;20(1):87-92. doi:10.1053/j.otsm.2012.03.010.
  8. Gross AE, Hutchison CR. Realignment osteotomy of the knee—Part 2: Proximal valgus tibial osteotomy for osteoarthritis of the varus knee. Operative Techniques in Sports Medicine. 2000;8(2):127-130. doi:10.1053/otsm.2000.6580.
  9. Cheng X, Liu F, Xiong F, Huang Y, Paulus AC. Radiographic changes and clinical outcomes after open and closed wedge high tibial osteotomy: a systematic review and meta-analysis. J Orthop Surg Res.2019;14(1):179. doi: 10.1186/s13018-019-1222-x.
  10. Erak S, Naudie D, MacDonald SJ, McCalden RW, Rorabeck CH, Bourne RB. Total knee arthroplasty following medial opening wedge tibial osteotomy: technical issues early clinical radiological results. Knee. 2011;18(6):499-504. doi:10.1016/j.knee.2010.11.002.
  11. Treuter S, Schuh A, Hönle W, Ismail MS, Chirag TN, Fujak A. Long-term results of total knee arthroplasty following high tibial osteotomy according to Wagner. Int Orthop. 2012;36(4):761-4. doi:10.1007/s00264-011-1373-9.
  12. Dragosloveanu S, Capitanu B-S, Dragosloveanu CI, Mihailescu A-A, Enayatollahi M, Scheau C. Comparative Efficacy and Safety of Intravenous vs. Combined Intravenous and Intraarticular Tranexamic Acid Administration in Total Knee Arthroplasty: A Stratified Analysis Based on Bleeding Risk. Arch Bone Jt Surg. 2025;13(10):622-630. doi:10.22038/abjs.2025.84997.3870.
  13. Elhence A, Gupta S, Roy S, et al. Total Knee Arthroplasty in End-Stage Knee Osteoarthritis with Tibia Stress Fractures – A Propensity Score Matched Comparative Study. Arch Bone Jt Surg. 2025;13(5):281-290. doi:10.22038/abjs.2024.78268.3601.
  14. Yu X, Zhuang R, Jin P. Evaluation of the efficacy after Total Knee Arthroplasty by Gait analysis in patients with Knee Osteoarthritis: a meta-analysis. J Orthop Surg Res. 2024;19(1):612. doi: 10.1186/s13018-024-05091-2.
  15. Koh IJ, Kim MW, Kim JH, Han SY, In Y. Trends in High Tibial Osteotomy and Knee Arthroplasty Utilizations and Demographics in Korea From 2009 to 2013. J Arthroplasty. 2015;30(6):939-44. doi:10.1016/j.arth.2015.01.002.
  16. Longo UG, Mazzola A, Campi S, et al. Annual trends of high tibial osteotomy: analysis of an official registry in Italy. Medicina (Kaunas).2024;60(7):1168. doi: 10.3390/medicina60071168.
  17. Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the US, 2014 to 2030. J Bone Joint Surg Am.2018;100(17):1455-1460. doi: 10.2106/JBJS.17.01617.
The Archives of Bone and Joint Surgery
Volume 14, Issue 7
July 2026
Pages 426-435

  • Receive Date 25 April 2026
  • Revise Date 18 May 2026
  • Accept Date 27 April 2026