Is There Still a Role for Tibial Osteotomy in Knee OA?

    Dr. Andrea Baldini says principle behind the procedure – to unload the compartment – is biomechanically sound.

    Guidelines on knee osteoarthritis (OA) from the American Academy of Orthopaedic Surgeons indicate that the evidence for tibial osteotomy in patients with OA is “limited.” The guidelines define “limited” as “unconvincing.” [1]

    The European literature, in contrast, embraces the procedure. For example, a 2013 editorial by Seil et al in the journal Knee Surgery Sports Traumatology Arthroscopy recommends that orthopaedic surgeons at least consider an osteotomy for every patient younger than age 60 to 65 with unicompartmental overload or OA. [2]

    Andrea Baldini, MD, from the IFCA Clinic in Florence, Italy, and the Humanitas Institute in Milan, Italy, is a proponent of tibial osteotomy – he even performed one on his brother-in-law, who, 5 years later, is doing well.

    Dr. Baldini recently spoke about the role of tibial osteotomy at the ICJR East meeting in New York. The principle behind the procedure – to unload the compartment – is biomechanically sound, he said. The “magic number” for the mechanical axis is 62% of the plateau. The surgeon will need to release the MCL in the open wedge for effective unloading, he said.

    He cited survival numbers for the procedure that he admitted are not what would be expected of a total knee arthroplasty, but that are acceptable given that they represent older techniques performed in younger patients:

    • 90% survival at 5 years
    • 77% survival at 10 years
    • 71% survival at 15 years

    For best results, Dr. Baldini urged appropriate patient selection – meaning patients with a varus morphotype only. He said that Lobenhoffer, who has a large osteotomy practice in Germany, has achieved the greatest success with patients whose tibial metaphyseal angle is greater than 5° and who have pure metaphyseal deformity. [3]

    An alternative to tibial osteotomy is unicompartmental knee arthroplasty (UKA). Fu recently published a meta-analysis of 11 studies comparing the two procedures. [4] UKA provided better function, but tibial osteotomy provided better range of motion. The two procedures were comparable in terms of knee score and complications. A recent study by Spahn had similar conclusions. [5]

    Orthopaedic surgeons are again performing opening wedge high tibial osteotomy due to new techniques and fixation, Dr. Baldini said. The development of fixed angular stable plates offers new opportunities for the procedure, while the introduction of navigation techniques allows for greater precision.

    The ideal patient for a tibial osteotomy, as defined in a consensus paper by the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), has the following attributes:

    • Isolated medial joint pain
    • Age 40 to 60 years
    • BMI less than 30
    • High demand, but not a jumper or runner
    • Malalignment of less than 15°
    • Metaphyseal varus of greater than 5°
    • Full range of motion
    • Normal ligaments
    • Ahlback score of 1 to 3
    • No lateral or patellar OA
    • Non-smoker

    That is the ideal. Dr. Baldini said a tibial osteotomy is also possible in the following situations:

    • Flexion contracture of no more than 15°
    • Age 60 to 70 years or less than age 40
    • ACL/PCL insufficiency
    • Moderate patellar OA
    • Patient wishes to continue all sports

    Dr. Baldini’s presentation is available on ICJR.net.


    1. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee. Evidence-based Guideline, 2nd Edition. Adopted May 18, 2013. Accessed January 2, 2014.
    2. Seil R, van Heerwaarden R, Lobenhoffer P, Kohn D. The Rapid Evolution of Knee Osteotomies Knee Surg Sports Traumatol Arthrosc 2013;21(1):1-2. 3.
    3. Lobenhoffer P, van Heerwaarden RJ, Staubli AE,Jakob RP, editors. Osteotomies Around the Knee: Indications-Planning-Surgical Techniques using Plate Fixators. 1st ed. Stuttgart, Germany: Thieme; 2008.
      Fu D, Li G, Chen K, Zhao Y, Hua Y, Cai Z. Comparison of High Tibial Osteotomy and Unicompartmental Knee Arthroplasty in the Treatment of Unicompartmental Osteoarthritis: A Meta-Analysis J Arthroplasty 2013;28(5):759-65.
    4. Spahn G, Hofmann GO, von Engelhardt LV, Li M, Neubauer H, Klinger HM. The Impact of aHigh Tibial Valgus Osteotomyand Unicondylar Medial Arthroplasty on the Treatment for Knee Osteoarthritis: A Meta-Analysis Knee Surg Sports Traumatol Arthrosc 2013;21(1):96-112.