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High Tibial Osteotomy (HTO) - Medial Opening Wedge

Comprehensive surgical technique guide for medial opening wedge high tibial osteotomy, including planning, fixation, and lateral hinge fracture management, for FRCS exam preparation

Core Procedure
intermediate
By OrthoVellum Medical Education Team

Reviewed by OrthoVellum Editorial Team

Editorial maintenance, source checking, and correction workflow • Published by OrthoVellum Medical Education Team

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High-yield overview

Joint Preservation Surgery | Core Procedure

Mnemonic

FUJISAWAFUJISAWA - Alignment Target

Mnemonic

HINGEHINGE - Lateral Cortex Preservation

Critical Danger Structures - Proximal Tibia

Common Peroneal Nerve

Wraps around fibular neck 10-20mm distal to fibular head. At highest risk with lateral closing wedge or fibular osteotomy. Medial approach avoids directly but posterolateral retractors can stretch it. Protection: Flex knee to relax nerve, avoid posterolateral retraction, palpate fibular neck before osteotomy.

Popliteal Neurovascular Bundle

Lies 5-10mm posterior to proximal tibia at osteotomy level. Risk with posterior saw penetration or aggressive osteotome placement. Protection: Use Hohmann retractor posteriorly, stop saw 10mm from posterior cortex, tactile awareness during osteotomy.

Infrapatellar Branch - Saphenous Nerve

Crosses anteromedial tibia 10-30mm below joint line - directly in surgical field. Injury causes anteromedial knee numbness. Protection: Full-thickness flap elevation, protect with retractor, warn patient of numbness risk preoperatively.

MCL and Pes Anserinus

MCL deep fibers attach to proximal tibia at osteotomy level. Pes anserinus lies superficially. Protection: Release superficial MCL subperiosteally, identify pes anserinus, preserve/repair at closure.

Ideal Patient Selection

Absolute Indications:

  • Isolated medial compartment OA (Ahlback Grade 1-3)
  • Constitutional varus malalignment greater than 5 degrees
  • Age less than 60-65 years (physiological age matters)
  • Active lifestyle incompatible with arthroplasty restrictions
  • Good knee range of motion (at least 0-120 degrees)
  • Intact ACL (or plan concurrent reconstruction)

Relative Indications:

  • Medial meniscectomy with early OA changes
  • Post-traumatic varus deformity
  • Combined with cartilage procedures (microfracture, OATS, ACI)

Contraindications:

  • Lateral compartment arthritis (bone-on-bone)
  • Patellofemoral arthritis (relative - depends on severity)
  • Fixed flexion deformity greater than 15 degrees
  • Inflammatory arthritis (RA)
  • Grade 4 medial OA with significant bone loss
  • Ligamentous instability (unless addressed)
  • BMI greater than 35-40 (relative)
  • Heavy manual labour with high failure risk

Equipment and Setup

Essential Equipment Checklist

Patient Positioning:

  • Supine on radiolucent table
  • Knee flexed 20-30 degrees over bolster
  • Thigh tourniquet (optional - improves visualisation)
  • Ensure full C-arm access - test before draping

Instrumentation:

  • HTO-specific instrument set (Synthes Tomofix, Arthrex, or similar)
  • Oscillating saw with narrow blade
  • Graduated osteotomes (set of increasing widths)
  • K-wires 2.0mm for guide placement
  • Depth gauge
  • Calibrated spreaders or lamina spreaders

Implants:

  • Tomofix medial HTO plate (or equivalent locking plate)
  • Locking screws 4.5mm or 5.0mm
  • Cortical screws if needed
  • Bone graft options (if gap greater than 10mm):
    • Iliac crest autograft
    • Allograft wedge
    • Synthetic bone substitute (beta-TCP, hydroxyapatite)

Fluoroscopy:

  • C-arm with surgeon driving capability
  • Alignment rod (long metal rod or diathermy cord)
  • Screen positioned for easy viewing

Operative Technique

Step 1: Positioning and Preparation

Position patient supine with knee flexed 20-30 degrees over sandbag or bolster. This relaxes the posterior structures. Apply thigh tourniquet but don't inflate unless necessary. Position C-arm from opposite side ensuring clear AP and lateral views of proximal tibia. Mark joint line, tibial tubercle, and planned incision under fluoroscopy.

Clinical Pearl

Technical Tip: Before draping, confirm C-arm can obtain true AP (tibial spines equidistant from tibial margins) and lateral views. Poor imaging wastes time and increases error risk.

Step 2: Incision and Superficial Dissection

Make 6-8cm longitudinal incision starting at joint line, centred between tibial tubercle and posteromedial tibial border. Curve slightly posteriorly distally. Incise fascia in line with skin. Identify pes anserinus (sartorius, gracilis, semitendinosus) - these lie superficial to MCL.

Nerve at Risk

The infrapatellar branch of saphenous nerve crosses this field. Elevate full-thickness fasciocutaneous flaps to protect it. Warn patients preoperatively that anteromedial knee numbness occurs in 20-30%.

Step 3: Deep Dissection and MCL Release

Release pes anserinus from tibial insertion with electrocautery or sharply - tag with suture for later repair. Identify superficial MCL fibres running obliquely across proximal tibia. Release MCL subperiosteally from tibia using elevator or electrocautery - this allows osteotomy opening without MCL strain.

Clinical Pearl

Technical Tip: The MCL must be released to allow osteotomy opening. If not released, opening the wedge will stretch and potentially rupture the MCL, causing postoperative instability.

Step 4: Exposure of Proximal Medial Tibia

Strip periosteum from anteromedial and posteromedial tibia from joint line to 5cm below. Place Hohmann retractor posteriorly directly on bone - this protects popliteal vessels which lie 5-10mm behind posterior tibial cortex. Place anterior retractor protecting patellar tendon and tibial tubercle.

Vascular Protection

The popliteal artery lies directly behind the posterior tibial cortex at this level. ALWAYS place a Hohmann retractor on bone posteriorly before any saw or osteotome use.

Step 5: Guide Wire Placement

Under fluoroscopy, insert first guide wire from medial cortex (below planned osteotomy) directed toward the lateral hinge point. The target is:

  • AP plane: aimed at fibular head/tip
  • Obliquity: ascending 10-15 degrees proximally
  • Endpoint: 10mm from lateral cortex (leave bone bridge for hinge)

Confirm wire position on AP and lateral - wire should be 35-40mm below joint line medially.

Clinical Pearl

Technical Tip: The guide wire defines the hinge point. Too proximal risks intra-articular fracture. Too distal limits correction. Aim for wire to exit 10mm below joint line at lateral cortex.

Step 6: Second Guide Wire for Biplanar Cut

Insert second guide wire parallel to first but directed anterosuperiorly toward tibial tubercle. This ascending limb creates the biplanar osteotomy which:

  1. Protects tibial tubercle attachment
  2. Prevents patellar tendon impingement
  3. Increases construct stability

The two wires should diverge by 100-110 degrees anteriorly.

Step 7: Horizontal Osteotomy

Using oscillating saw with narrow blade, cut between the two guide wires:

  • Start at posteromedial cortex
  • Progress anteriorly staying parallel to main wire
  • Stop 10mm from lateral cortex (preserve hinge)
  • Copious irrigation during sawing to prevent thermal necrosis
  • Complete posterior cortex cut with osteotome if needed

Critical Step - Hinge Preservation

Do NOT penetrate the lateral cortex. The lateral hinge provides stability and maintains blood supply. An unstable lateral hinge fracture (Takeuchi Type II, propagating distal to the proximal tibiofibular joint) increases delayed-union and loss-of-correction risk and may require supplementary fixation or protected weight-bearing.

Step 8: Ascending Limb (Biplanar Cut)

Complete the ascending limb from main osteotomy toward tibial tubercle:

  • 45-degree angle from horizontal cut
  • Exits proximal to tubercle insertion
  • Creates L-shaped osteotomy pattern
  • Preserves patellar tendon attachment

Clinical Pearl

Technical Tip: The biplanar technique creates a larger surface area for healing and protects the extensor mechanism. It has become standard over simple transverse cuts.

Step 9: Controlled Osteotomy Opening

Using thin osteotomes, gradually open the osteotomy:

  1. Insert thin osteotome at posteromedial corner
  2. Gently lever to initiate opening
  3. Insert second osteotome anteriorly
  4. Stack progressively wider osteotomes
  5. Advance slowly - feel for hinge maintaining integrity
  6. Open to calculated distance (measured with depth gauge)

Opening Technique

Open SLOWLY and GRADUALLY. Rapid forced opening fractures the lateral hinge. If significant resistance encountered, check for incomplete posterior cut and extend with osteotome.

Step 10: Alignment Verification

With osteotomy held open at planned correction, verify alignment:

Cable Method:

  1. Hold alignment rod from hip (ASIS for proxy) to ankle centre
  2. Check rod passes through Fujisawa point (62% tibial plateau)
  3. Adjust opening until rod position correct

Grid Method:

  1. Place alignment grid on tibial plateau under fluoro
  2. Measure mechanical axis position as percentage

Target: mechanical axis through 62-66% of tibial plateau from medial side.

Clinical Pearl

Technical Tip: Better to slightly overcorrect (65%) than undercorrect. Undercorrection is commonest cause of early failure. The knee will look slightly valgus on table - this is correct.

Step 11: Plate Application - Tomofix

Apply medial locking plate (Tomofix or similar):

  1. Position plate on anteromedial tibial surface
  2. Proximal end should not impinge on MCL
  3. Check plate position on AP and lateral fluoro
  4. Insert proximal locking screws (2-4 screws)
  5. Insert distal locking screws (2-4 screws)
  6. Screws should be bicortical where possible

Clinical Pearl

Technical Tip: The Tomofix plate has a spacer portion that maintains correction angle. Some systems use separate wedge inserts. Ensure screws don't penetrate the joint - check on lateral view.

Step 12: Gap Management

Assess osteotomy gap:

Gap less than 7mm: Can leave empty - will heal with haematoma

Gap 7-10mm: Consider bone graft or substitute

Gap greater than 10mm: Bone graft strongly recommended

  • Iliac crest autograft (gold standard)
  • Structural allograft wedge
  • Synthetic wedge (beta-TCP, hydroxyapatite)

Pack graft into osteotomy gap ensuring posterior and lateral defect filled.

Step 13: Final Checks and Closure

Complete surgical checklist:

  • Alignment confirmed (Fujisawa point)
  • Plate position confirmed on AP and lateral
  • No screw penetration of joint
  • Osteotomy gap filled if indicated
  • Lateral hinge intact or only partial crack
  • Tourniquet down, haemostasis achieved

Closure:

  1. Repair pes anserinus if released (2-0 absorbable)
  2. Close fascia over plate
  3. Subcutaneous 2-0 absorbable
  4. Skin staples or subcuticular

Dressing and wool/crepe or knee immobiliser.

Managing Lateral Hinge Fracture

Intraoperative Lateral Hinge Fracture

If complete lateral hinge fracture occurs during opening:

  1. STOP opening immediately
  2. Assess fracture pattern on fluoroscopy
  3. Classify with the Takeuchi system (see below) and act accordingly:
    • Type I (proximal to/within the tibiofibular joint - most common): usually stable, proceed with standard medial fixation
    • Type II (distal to the tibiofibular joint - least stable): protect weight-bearing or add supplementary lateral fixation
    • Type III (lateral plateau fracture): reduce and fix the plateau component before relying on the medial construct

Recognition: Sudden "give" during opening, instability on manipulation, fracture line visible on fluoro

Fracture Classification (Takeuchi, Arthroscopy 2012):

  • Type I: Fracture line reaches just proximal to, or within, the proximal tibiofibular joint - the commonest pattern (roughly three-quarters of hinge fractures) and the most benign. The intact tibiofibular ligaments confer relative stability.
  • Type II: Fracture reaches the distal portion of the proximal tibiofibular joint - the least stable pattern, carrying the highest risk of delayed union and loss of correction.
  • Type III: Lateral tibial plateau fracture - intra-articular extension with the worst prognosis, effectively converting the osteotomy into a plateau fracture.

Management by Type:

  • Type I: Often stable - standard medial Tomofix fixation usually suffices; may proceed with the planned rehabilitation, with closer radiographic surveillance.
  • Type II: Least stable - protect with non-weight-bearing or add supplementary lateral fixation; in Takeuchi's series the delayed unions and correction loss occurred almost exclusively in this group.
  • Type III: Intra-articular - reduce and stabilise the lateral plateau component (lag screw or lateral plate) before relying on the medial construct; protected weight-bearing until callus is visible.

Complications

HTO Complications - Recognition and Management

Post-operative Protocol

Immediate Post-operative (Days 0-7)

  • Knee immobiliser or hinged brace
  • Touch weight-bearing only with crutches
  • Gentle ROM exercises 0-90 degrees
  • DVT prophylaxis: LMWH for 2-4 weeks
  • Check X-ray before discharge

Early Rehabilitation (Weeks 2-6)

  • Continue touch weight-bearing
  • Progress ROM to 0-120 degrees
  • Quadriceps strengthening (isometric, SLR)
  • Stationary cycling when ROM allows
  • X-ray at 6 weeks to assess healing

Progressive Loading (Weeks 6-12)

  • If radiographic consolidation: progress to 50% weight-bearing week 6-8
  • Full weight-bearing by week 8-12
  • Proprioception and balance exercises
  • Pool therapy
  • Repeat X-ray at 12 weeks

Return to Activity (Months 3-12)

  • Low-impact sport from 4-6 months (swimming, cycling)
  • Running from 6 months if healed
  • Contact/cutting sport from 9-12 months
  • Hardware removal if symptomatic (after 12-18 months)

Follow-up Schedule

  • 2 weeks: wound check
  • 6 weeks: X-ray, progress weight-bearing
  • 12 weeks: X-ray, typically full weight-bearing
  • 6 months: functional assessment
  • 12 months: final assessment, long leg films
  • Annual review if symptoms recur

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 48-year-old keen recreational cyclist presents with 2 years of medial knee pain, worse with activity. Examination shows mild varus alignment and medial joint line tenderness. X-rays show medial compartment osteoarthritis with joint space narrowing. He wants to avoid knee replacement as long as possible. What are your treatment options?"

PRACTICAL APPROACH
This patient is a good candidate for joint-preserving surgery given his age, activity level, and isolated medial compartment disease. I would assess him systematically: First, non-operative management should be optimised - activity modification, physiotherapy for quadriceps strengthening, weight management if relevant, simple analgesia, and potentially injection therapy (steroid or hyaluronic acid). For imaging, I'd obtain weight-bearing long leg films to quantify any varus malalignment and MRI to confirm lateral compartment integrity and assess meniscal status. If constitutional varus malalignment is present (typically greater than 5 degrees mechanical axis deviation) with isolated medial disease and intact lateral compartment, high tibial osteotomy would be my recommended joint-preserving option. The principle is to unload the medial compartment by realigning the mechanical axis to pass through the Fujisawa point - 62% across the tibial plateau from medial to lateral. This shifts load to the healthier lateral compartment. Alternative surgical options include unicompartmental knee replacement, which has excellent outcomes but commits to arthroplasty pathway, or arthroscopic debridement which has limited evidence in osteoarthritis. Total knee arthroplasty would be a last resort given his age and activity - modern TKA can allow cycling but has activity restrictions and finite lifespan. For HTO specifically, ideal candidates are under 60-65, have good ROM (at least 0-120), intact ACL, BMI under 35, and realistic expectations. My preferred technique is medial opening wedge osteotomy with locking plate fixation (Tomofix), which avoids fibular osteotomy and peroneal nerve risk of the lateral closing wedge approach. Expected outcomes are 80-90% good/excellent results at 10 years, potentially delaying arthroplasty 10-15 years.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"During medial opening wedge HTO on a 52-year-old patient, you are gradually opening the osteotomy when you feel a sudden 'give' and see the lateral cortex has fractured completely on fluoroscopy. How do you manage this?"

PRACTICAL APPROACH
This is a lateral hinge fracture - a recognised complication occurring in 5-20% of cases that significantly impacts stability and healing. I would stop opening immediately and assess the situation systematically. First, I'd characterise the fracture using the Takeuchi classification: Type I reaches just proximal to or within the proximal tibiofibular joint (commonest, most benign), Type II reaches distal to the proximal tibiofibular joint (least stable, highest delayed-union risk), and Type III is a lateral tibial plateau fracture (intra-articular, worst prognosis). This guides management. With complete hinge loss, I've lost the inherent stability that the intact hinge provides. My options depend on fracture pattern: For a Type II fracture, which is the least stable, I would either protect with non-weight-bearing or supplement the medial Tomofix with a lateral locking plate to create a dual-plate construct bridging the fracture. A Type I fracture is usually stable and can often be managed with standard medial fixation and closer radiographic surveillance. For a Type III fracture extending into the joint, I would address the articular component first. If the lateral plateau fracture is minimally displaced and can be compressed with a lag screw or lateral plate, I would reduce and fix it before relying on the medial construct. If significantly displaced or comminuted, this has become an intra-articular plateau fracture requiring formal ORIF of the plateau component. Postoperatively, a patient with lateral hinge fracture requires more protected weight-bearing (potentially 8-12 weeks touch weight-bearing instead of 6), closer radiographic surveillance, and counselling about increased non-union risk. Prevention is key - gradual opening, drilling weakening holes in the lateral cortex, stopping the saw 10mm from the lateral cortex, and using graduated osteotomes rather than forcing the opening.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 54-year-old woman had a HTO performed elsewhere 8 years ago. She now presents with increasing pain affecting both medial and lateral compartments, mechanical symptoms, and difficulty walking more than 500 metres. Examination shows 8 degrees valgus alignment, small effusion, and diffuse joint line tenderness. X-rays show tricompartmental arthritis. She asks about further surgery. What are the considerations?"

PRACTICAL APPROACH
This patient has progression of arthritis following HTO - a recognised long-term outcome even after technically successful osteotomy. The original HTO has served its purpose in delaying arthroplasty but she now has symptomatic tricompartmental disease requiring definitive management. The main consideration is conversion to total knee arthroplasty. This is a more complex procedure following HTO due to several factors: First, the altered anatomy - her tibia is now in valgus alignment which affects both bony cuts and soft tissue balancing. The proximal tibial anatomy is changed with potential hardware in situ, sclerotic bone at the osteotomy site, and potentially altered joint line height. Second, the retained hardware - the Tomofix plate needs removal either as a staged procedure (plate out, wait 3 months, then TKA) or at the same time. I prefer staged removal unless hardware is minimal, as it allows assessment of bone quality and any defects. Surgical planning for TKA post-HTO requires: Long leg films to assess current alignment, CT if concerned about hardware trajectory or bone stock, templating that accounts for altered anatomy. Intraoperatively, I'd expect longer operative time, potential need for augments or stems if bone defects, and careful soft tissue balancing given the altered mechanics. The evidence suggests TKA following HTO has outcomes approaching primary TKA, though some series show slightly higher complication rates and revision rates at 10 years. Conversion to UKA would not be appropriate given her tricompartmental disease. Non-operative measures at this stage are palliative only. I would counsel her that TKA is indicated and will provide excellent pain relief and function improvement, while acknowledging it's a bigger procedure than primary TKA with slightly increased complexity.

High Tibial Osteotomy - Exam Summary

Clinical summary

Evidence Base

Improvements in surgical technique of valgus high tibial osteotomy

Level IV
Lobenhoffer P, Agneskirchner JD • Knee Surg Sports Traumatol Arthrosc
Clinical Implication: This is the foundational technique paper for medial open-wedge HTO and underpins the modern biplanar, hinge-preserving, locking-plate technique described here.
Verify on PubMed (PMID 12774149)

Fractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: a new classification of lateral hinge fracture

Level IV
Takeuchi R, Ishikawa H, Kumagai K, et al • Arthroscopy
Clinical Implication: The Takeuchi classification stratifies hinge-fracture severity: Type I is usually benign, Type II is the least stable and needs protection or supplementary fixation, and Type III requires articular reduction.
Verify on PubMed (PMID 21982387)

The long-term outcome of high tibial osteotomy: a ten- to 20-year follow-up

Level IV
Akizuki S, Shibakawa A, Takizawa T, et al • J Bone Joint Surg Br
Clinical Implication: Provides the durable long-term survivorship figures used in consent and confirms that careful patient selection (lower BMI, good ROM) drives long-term success.
Verify on PubMed (PMID 18450624)

Opening-wedge high tibial osteotomy with locking plate fixation (TomoFix) and early weight-bearing without filling the defect: 48 cases at 10 years

Level IV
Darees M, Putman S, Brosset T, et al • Orthop Traumatol Surg Res
Clinical Implication: A rigid medial locking plate maintains correction over a decade and allows the gap to be left ungrafted in small-to-moderate corrections, simplifying the procedure.
Verify on PubMed (PMID 29572182)

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis

Level II
van Haeringen MH, Kuijer PPFM, Daams JG, et al • Knee Surg Sports Traumatol Arthrosc
Clinical Implication: Choice of open vs closing wedge can be individualised; closing wedge is preferable when avoiding slope increase matters (e.g. ACL-deficient knee), and early weight-bearing is reasonable when the hinge is intact.
Verify on PubMed (PMID 36473985)

Guidelines, Registries & Global Practice

HTO is endorsed across major societies as a joint-preserving option for symptomatic isolated medial-compartment osteoarthritis with varus malalignment in the younger, active patient who is not yet a candidate for arthroplasty.

  • NICE / BOA (UK): Osteotomy is recognised for selected unicompartmental OA with malalignment as an alternative to arthroplasty; emphasis on optimised non-operative care first.
  • AAOS (US): Osteotomy considered for the young, active patient with unicompartmental disease and deformity, when arthroplasty restrictions are undesirable.
  • ESSKA / European consensus: Supports medial open-wedge HTO with locking-plate fixation, biplanar cut and hinge preservation as the contemporary standard; recommends digital alignment planning and the Fujisawa point as the correction target.
  • Registry signal: Arthroplasty registries show conversion-to-TKA after prior HTO performs close to primary TKA in survivorship, though with modestly higher complexity - supporting HTO as a legitimate "first procedure" that does not preclude later arthroplasty.

Global practice variation: Open-wedge medial HTO predominates in Europe and much of Asia; lateral closing-wedge remains common where slope-neutral correction or larger corrections are favoured. Void filling (graft vs none) varies by gap size and surgeon preference rather than by region.

References

  1. Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2003;11(3):132-138.

  2. 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.

  3. Takeuchi R, Ishikawa H, Kumagai K, et al. Fractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: a new classification of lateral hinge fracture. Arthroscopy. 2012;28(1):85-94.

  4. Spahn G, Kirschbaum S, Kahl E. Factors that influence high tibial osteotomy results in patients with medial gonarthritis: a score to predict the results. Osteoarthritis Cartilage. 2006;14(2):190-195.

  5. 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):282-296.

  6. Amendola A, Panarella L. High tibial osteotomy for the treatment of unicompartmental arthritis of the knee. Orthop Clin North Am. 2005;36(4):497-504.

  7. Staubli AE, De Simoni C, Babst R, Lobenhoffer P. TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia - early results in 92 cases. Injury. 2003;34(Suppl 2):B55-B62.

  8. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646.

  9. Bonasia DE, Dettoni F, Sito G, et al. Medial opening wedge high tibial osteotomy for medial compartment overload/arthritis in the varus knee: prognostic factors. Am J Sports Med. 2014;42(3):690-698.

  10. Woodacre T, Ricketts M, Evans JT, et al. Complications associated with opening wedge high tibial osteotomy - a review of the literature and of 15 years of experience. Knee. 2016;23(2):276-282.

  11. Akizuki S, Shibakawa A, Takizawa T, et al. The long-term outcome of high tibial osteotomy: a ten- to 20-year follow-up. J Bone Joint Surg Br. 2008;90(5):592-596.

  12. Darees M, Putman S, Brosset T, et al. Opening-wedge high tibial osteotomy performed with locking plate fixation (TomoFix) and early weight-bearing but without filling the defect: a concise follow-up note of 48 cases at 10 years. Orthop Traumatol Surg Res. 2018;104(4):477-480.

  13. van Haeringen MH, Kuijer PPFM, Daams JG, et al. Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2023;31(7):3015-3026.