Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1750–1756

https://doi.org/10.1007/s00167-019-05596-y

KNEE

Distal tuberosity osteotomy in open‑wedge high tibial osteotomy

does not exacerbate patellofemoral osteoarthritis on arthroscopic
evaluation
Tomohiro Horikawa1 · Kenji Kubota1 · Shintaro Hara1 · Yukio Akasaki2 

Received: 10 January 2019 / Accepted: 24 June 2019 / Published online: 28 June 2019
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Abstract
Purpose  The purpose of the present study was to use arthroscopy to evaluate the effect of distal tuberosity osteotomy (DTO)
in open-wedge high tibial osteotomy (OW-HTO) on patellofemoral (PF) cartilage degradation.
Methods  Between 2012 and 2017, 46 knees underwent DTO in OW-HTO, and 65 knees underwent conventional OW-HTO
(cOW-HTO). To assess changes in patellar height, the Blackburne–Peel (BP) ratio and the Caton–Deschamps (CD) index
were measured. Arthroscopic evaluation on the PF joint was performed at the initial osteotomy and at the second-look pro-
cedure 1 year later. Statistical analyses were performed to compare difference between the DTO and the cOW-HTO group.
Results  In the cOW-HTO group, the mean BP ratio and CD index decreased significantly from 0.81 and 0.89 preoperatively,
respectively, to 0.69 and 0.76 postoperatively, respectively (p < 0.001). In contrast, the DTO group maintained a consistent
patellar height; the mean BP ratio and CD index were 0.77 and 0.83 preoperatively, respectively, and 0.73 and 0.80 postop-
eratively, respectively. Upon arthroscopic evaluation, 39 of 46 patients (84.8%) in the DTO group showed no progression of
PF cartilage degradation at the second look; indeed, five of 46 patients (10.9%) even demonstrated improvement. In contrast,
21 of 65 patients (32.3%) in the cOW-HTO group exhibited increased PF cartilage degradation. There was a significant dif-
ference in progression of PF cartilage degradation between DTO and cOW-HTO (p < 0.001).
Conclusion  DTO in OW-HTO maintained the preoperative patellar height, which could help prevent progression of carti-
lage degeneration in the PF joint after surgery. In respect of the biplanar osteotomy direction in OW-HTO, the DTO, rather
than cOWHTO, is the preferred technique for the treatment of varus knee osteoarthritis to avoid progression of PF cartilage
degradation.
Level of evidence III.

Keywords  Osteoarthritis · DTO · Distal tuberosity osteotomy · High tibial osteotomy · OWHTO · Patellar height ·
Patellofemoral osteoarthritis

Abbreviations DTO Distal tuberosity osteotomy

HTO High tibial osteotomy CD Caton–Deschamps
OA Osteoarthritis BMI Body mass index
OW Open-wedge BP Blackburne–Peel
cOW-HTO Conventional open-wedge high tibial FTA Femoro-tibial angle
osteotomy JOA Japanese Orthopaedic Association
PF Patellofemoral ICRS International Cartilage Repair Society

* Yukio Akasaki Introduction

akasaki@ortho.med.kyushu‑u.ac.jp
1
Department of Orthopaedic Surgery, Omuta Tenryo High tibial osteotomy (HTO) is an established therapeutic
Hospital, 1‑100, Tenryomachi, Omuta 836‑8566, Japan option for osteoarthritis (OA) with varus malalignment [1,
2
Department of Orthopaedic Surgery, Kyushu University, 23, 25]. In recent years, the open-wedge (OW) technique
3‑1‑1, Maidashi, Higashi‑ku, Fukuoka 812‑8582, Japan has gained popularity due to its use of rigid fixation that

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Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1750–1756 1751
allows for early postoperative weight-bearing [4]. However,
the conventional open-wedge high tibial osteotomy (cOW-
HTO) technique is associated with patellofemoral (PF) joint
problems caused by changes in patellar height [3, 5, 16, 22,
26] and tilt, leading to increased pressure [28] and PF joint
maltracking. These complications lead to PF OA progres-
sion [10, 13, 30].
To minimize these problems, distal tuberosity osteotomy
(DTO) in OW-HTO has been introduced as a new technique
to prevent distalization of the tuberosity [7, 9, 12, 15, 18,
21]. With this frontal retrotubercle descending cut proce-
dure, the normal anatomy of the PF joint is relatively pre-
served in OW-HTO; in particular, the Q-angles, axial axes
of the patella, and height of the patella are less altered than
with cOW-HTO, in which the frontal retrotubercle cut is
ascending. Gaasbeek et al. [9] concluded that DTO was
superior to cOW-HTO in terms of preventing a decrease
of patellar height as measured with the Caton–Deschamps
(CD) index. Radiographic analyses in previous studies also
demonstrated that DTO in OW-HTO minimized the decrease
in patellar height [7, 12, 15, 18, 21, 24]. However, no prior
studies have arthroscopically evaluated cartilage degenera-
tion in the PF joint after DTO in OW-HTO.
Whether the DTO technique can prevent PF OA progres-
sion after OW-HTO is still unclear. The purpose of this study
was to compare the results of DTO in OW-HTO with those
of cOW-HTO, especially regarding changes in PF OA, using
arthroscopy at initial surgery and at second-look surgery
with plate removal. It was hypothesized that the DTO tech-
nique could maintain the patella height and subsequently
minimize OA progression in the PF joint after OW-HTO.
These findings would underscore the importance of the
patellar height assessment and the choice of the biplanar
osteotomy direction in OW-HTO.
Materials and methods
Patient recruitment
Between 2012 and 2017, OW-HTO was performed on 111
knees of 98 patients with medial compartment OA of the
knee at Omuta Tenryo Hospital. The study population com-
prised 32 men and 66 women, with a mean age of 62.8 ± 6.6
(range 43–79) years and a mean body mass index (BMI) of
26.7 ± 4.1 (range 17.3–36.2) kg/m2. The indication for sur-
gery was varus deformity with persistent pain at the medial
side of the knee after at least 3 months of conservative treat-
ment. Patients with PF joint space narrowing and/or osteo-
phytes on radiograph were included if they were non-symp-
tomatic by patella grinding test preoperatively. Patients with
lateral compartmental cartilage lesions, as defined on mag-
netic resonance imaging and diagnosed during arthroscopy,
were excluded from surgery. None of the patients had an
anterior or posterior cruciate ligament deficiency. There was
no age restriction.
Surgical technique and postoperative rehabilitation
Forty-six knees of 39 patients (17 men and 22 women)
underwent DTO in OW-HTO, and 65 knees of 59 patients
(12 men and 44 women) underwent cOW-HTO. Surgical
procedures were performed by two surgeons (the first and
second authors). The presence of either a preoperative calcu-
lated correction angle over 12° or PF joint space narrowing
on radiograph or grade 3–4 of ICRS intra-operatively were
our predominant indication for DTO.
In preoperative planning, the correction angle was deter-
mined by aiming for a postoperative weight-bearing axis at
a point 62.5% lateral to the transverse diameter of the tibial
plateau on a whole-leg radiograph. Diagnostic arthroscopy
was conducted before osteotomy to evaluate the extent of
cartilage degradation in the medial, lateral, and PF com-
partments, followed by meniscal debridement as necessary.
Concomitant partial menisectomy was conducted in 20 of 46
DTO and in 45 of 65 cOW-HTO, respectively. None of the
patients underwent any cartilage repair procedure at initial
arthroscopy.
DTO was performed as detailed by Gaasbeck et al. [9].
In contrast to the conventional technique with ascending cut
of the tuberosity, the cut of the tuberosity was performed
distally in the frontal plane and directed towards the ante-
rior tibial cortex (Fig. 1). The length of the osteotomized
tuberosity was at least 2.5 cm so as to overlap with the distal
tibial segment after the wedge was opened (Fig. 1). In this
process, the tuberosity remained proximally attached to the
tibia. Following medial plate fixation, the distal part of the
tuberosity was fixed with a bicortical screw to the posterior
tibial cortex (Fig. 1). After stable fixation was reached, the
postoperative rehabilitation protocol for DTO was the same
as for cOW-HTO. Postoperatively, partial weight-bearing
began on postoperative day 7 and full weight-bearing on
postoperative day 21.
Radiological and clinical assessments
Measurements were performed using preoperative and
1-year postoperative follow-up radiographs. The Black-
burne–Peel (BP) ratio and the CD index were determined
on lateral knee radiographs to assess patellar height. The
posterior tibial slope was measured as the angle between
the line perpendicular to the anterior tibial cortex and
the line parallel to the medial tibial plateau on lateral
radiographs. Pre- and postoperative femoro-tibial angle
(FTA) were measured on antero-posterior radiographs.
All images were imported into a digital imaging software
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1752 Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1750–1756

assessment preoperatively and at 1 year after osteotomy

[19].

Arthroscopic assessment

The PF articular cartilage was assessed by arthroscopy at

the initial surgery and at second-look surgery with plate
removal. Chondral lesions of the femoral trochlear cartilage
were graded using the International Cartilage Repair Soci-
ety (ICRS) grading system by two observers (the first and
second authors) by consensus. If there was any progressive
change at the second look compared to the initial surgery,
the case was defined as progression; if there was no change,
the case was defined as unchanged; and if there was positive
change, the case was defined as improvement.
This study was approved by the institutional review board
of Omuta Tenryo Hospital and Kyushu University (ID num-
ber of the approval: 28-366) as a retrospective case series.

Statistical analysis

Student’s t test and Fisher’s exact test were used to analyse

Fig. 1  Representative lateral radiograph after DTO. The descending
cut of the tuberosity was performed in the frontal plane. Following
medial plate fixation, the distal part of the tuberosity was fixed with a
bicortical screw to the posterior tibial cortex
(DV-R PACS application, CANON medical, Japan) that
measures distance and angle with one decimal. To deter-
mine the test–retest reliability, all radiographic assessment
was performed twice on 20 randomly selected radiographs
at an interval of more than 2 weeks. The test–retest reli-
abilities of all radiographic measurement were evaluated
using intraclass correlation coefficients, which were > 0.8
(range 0.83–0.89) for all measurement. The Japanese
Orthopaedic Association (JOA) score was used for clinical
group differences. The data were expressed as the mean,
standard deviation, and range. All variables were normally
distributed. Statistical analyses were performed using
JMP software version 11.0.2 (SAS, Cary, NC, USA). A p
value < 0.01 was considered to indicate statistical signifi-
cance. In post hoc power analysis, the power of the present
study regarding BP ratio and CD index was 0.99 and 0.99
with effect size of 0.92 and 1.00, respectively, when sample
size was 46 and 65 in the DTO and cOW-HTO groups.
Results
The characteristics of patients in the DTO and cOW-HTO
groups are summarized in Table 1. Mean preoperative FTA
in the DTO group was significantly more varus than that
in the cOW-HTO (p < 0.001). There was no significant dif-
ference in mean postoperative FTA between two groups.

Table 1  Patient characteristics DTO cOW-HTO p value

Number of patients 46 65
Age (years) 62.6 ± 6.2 (50–79) 63.0 ± 7.1 (49–78) n.s.
Gender (male/female) (19/27) (17/48) n.s.
Body mass index (kg/m2) 27.1 ± 3.8 (20.1–35.7) 26.3 ± 4.3 (17.3–36.2) n.s.
Opening wedge size (mm) 13.3 ± 3.2 (6–22) 9.96 ± 2.3 (5–15) < 0.001
Preoperative FTA 182.8 ± 4.1 (174.4–193.4) 178.5 ± 3.0 (170.6–185.8) < 0.001
Postoperative FTA 170.8 ± 3.7 (162.1–179.9) 169.2 ± 3.7 (164.1–176.2) n.s.
Preoperative JOA score 76.3 ± 7.5 (55–90) 77.9 ± 7.3 (60–90) n.s.
Postoperative JOA score 91.0 ± 5.8 (80–100) 92.3 ± 5.1 (80–100) n.s.

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Table 2  Radiological assessments
DTO cOW-HTO
Pre-op Post-op p value Pre-op Post-op p value

Blackburne–Peel 0.77 ± 0.12 (0.53–1.00) 0.73 ± 0.13 (0.50–0.98) n.s. 0.81 ± 0.13 (0.53–1.13) 0.69 ± 0.13 (0.42–0.97) < 0.001
Caton–Deschamps 0.83 ± 0.14 (0.56–1.15) 0.80 ± 0.14 (0.53–1.12) n.s. 0.89 ± 0.13 (0.59–1.18) 0.76 ± 0.13 (0.40–1.01) < 0.001
Posterior tibial slope 9.7 ± 2.5 (3.6–15.4) 9.9 ± 3.6 (1.9–16.7) n.s. 10.2 ± 2.8 (1.3–14.7) 10.6 ± 3.3 (2.8–17.5) n.s.

Table 3  Inter- and intra-rater reliability for ICRS grading patients (10.9%) demonstrated improved cartilage lesions,
Kappa coefficient
and only two cases progressed. In contrast, 21 of 65 patients
(32.3%) in the cOW-HTO group showed progression of PF
Pre-op Post-op cartilage degradation. There was a significant difference in
Observer 1 intra-rater reliability 0.7104 0.734 progression of PF cartilage degradation between DTO and
Observer 2 intra-rater reliability 0.853 0.738 cOW-HTO (p < 0.001). Representative arthroscopic findings
Inter-rater reliability 0.845 0.871 after DTO and cOW-HTO are shown in Fig. 2.

Table 4  ICRS grades for the femoral trochlear cartilage

ICRS grade DTO cOW-HTO
Pre-op Post-op Pre-op
1 0 0 36
2 20 22 19
3 24 23 9 18
4 2 1 1
In both group, the JOA score significantly improved after
osteotomy (p < 0.001). There was no significant difference
in pre- and postoperative JOA score between the DTO and
the cOW-HTO group.
In the cOW-HTO group, the mean and standard devia-
tion of BP ratio and CD index decreased significantly, from
0.81 ± 0.13 and 0.89 ± 0.13 preoperatively, respectively, to
0.69 ± 0.13 and 0.76 ± 0.13 postoperatively, respectively
(p < 0.001) (Table 2). In contrast, the DTO group maintained
the patellar height assessed by the BP ratio and CD index.
The posterior tibial slope did not significantly changed after
surgery both in the DTO and the cOW-HTO group (Table 2).
In arthroscopic evaluation, acceptable inter- and intra-
rater reliability for ICRS grading are shown in Table 3. The
ICRS grades at the initial surgery and at second-look surgery
in both groups are shown in Table 4. In Table 5, 39 of 46
patients (84.8%) in the DTO group did not exhibit increased
PF cartilage degradation at the second look. Five of 46
Discussion
Post-op The most important finding of the present study was that the
DTO technique prevented the progression of PF cartilage
24 degradation, which is known to be a potential problem after
20 cOW-HTO [10, 13, 30]. This is the first study to use arthros-
copy to evaluate the progression of cartilage degradation in
3 the PF joint after DTO in OW-HTO. Most patients (44 of
46, 95.6%) in the DTO group did not exhibit progression of
cartilage degradation in the PF joint at second-look arthros-
copy; in fact, chondral lesions actually improved in 5 of 46
patients (10.9%). In contrast, 22 of 70 patients (31.4%) in
the cOW-HTO group showed PF OA progression on arthro-
scopic assessment.
In the DTO technique, the tibial tuberosity remains
attached to the proximal tibia, theoretically maintaining the
patellar height after OW-HTO. BP and CD indices are use-
ful for radiographical assessment of the patellar height that
could be influenced by the change of tibial tuberosity [15].
In fact, the present study showed that the patellar height
was unchanged after DTO in OW-HTO, which is consist-
ent with the findings of previous studies [7, 9, 12, 15, 18,
21, 24]. Decreased patellar height after cOW-HTO in the
present study is considered as one of the most critical fac-
tors leading to PF joint deterioration in cOW-HTO group.
A cadaveric study [28] found that PF cartilage contact pres-
sure after cOW-HTO was significantly elevated at 30°, 60°,
and 90° of knee flexion. In contrast, DTO had no significant

Table 5  Arthroscopic DTO cOW-HTO

assessments
Improvement Unchanged Progression Improvement Unchanged Progression

5 (10.9%) 39 (84.8%) 2 (4.3%) 0 (0%) 44 (67.7%) 21 (32.3%)

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Fig. 2  Representative arthro-
scopic findings of DTO and
cOW-HTO. Preoperative ICRS
grade 4 cartilage lesion (a) in
the DTO group improved to
grade 3 postoperatively (b).
In contrast, in the cOW-HTO,
preoperative ICRS grade 3
lesion (c) degraded to grade 4
postoperatively (d)
effect on PF contact pressure, and maintained normal joint
biomechanics by preventing changes in the position of the
patella on the patellar groove of the femur. Recent cadav-
eric study [14] also reported that OW-HTO with a distally
directed biplanar osteotomy of the tuberosity significantly
diminished patellofemoral pressure increase depending on
the correction angle. Patellar maltracking, such as increased
medial patellar tilt and reduced medial patellar rotation, has
been reported as another cause of abnormal PF biomechan-
ics after cOW-HTO [2, 8]. Collectively, the DTO in OW-
HTO is a preferred technique to avoid undesirable pressure
elevation and maltracking in the PF joint.
The closing-wedge method maintains patellar height after
high tibial osteotomy and is an important option that prom-
ises good long-term clinical outcomes [25]. Recently, hybrid
HTO, which combines medical opening and lateral closing
technique, has been proposed [29] and reported improved
joint space and congruence angle at PF joint after hybrid
HTO compared to OW-HTO [11, 20]. However, the OW
technique has several advantages over the closing-wedge
method, namely faster and easier, more precise correction
of the mechanical axis, lower risk of damaging the pero-
neal nerve, and lower incidence of compartment syndrome
[25]. The goal of the DTO technique is to achieve these
advantages of the OW technique without the potential PF
problems associated with cOW-HTO.
The indications for DTO have been proposed by previous
researchers, and depend on preoperative factors such as the
patellar height, calculated correction angle, and severity of
PF OA. Gaasbeek et al. first recommended DTO for patients
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Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1750–1756
with patella infera and/or a correction angle over 10° [9].
Similarly, Brinkman et al. reported that the DTO procedure
was indicated for patients with patella infera and a correction
angle over 8°–10° [4]. El-Azab et al. recommended DTO or
closing-wedge HTO for patients with patella infera or PF
OA [6]. In the present study, whether to use an ascending or
descending frontal retrotubercle cut procedure was decided
by surgeon’s decision based on the calculated preoperative
correction opening wedge size or the presence of PF OA in
the preoperative and intra-operative assessment. A prospec-
tive comparison study is necessary to determine the appro-
priate indications for DTO.
Up to the present, clinical impact after DTO on PF joint
has not been elucidated. In this study, there was no signifi-
cant difference in the postoperative JOA score between the
DTO and the cOW-HTO group. Several previous studies
have reported that the progression of PF OA after cOW-HTO
did not significantly affect the clinical outcomes [17, 27].
More recent report also reported no significant effect of PF
OA progression after cOW-HTO on the clinical outcomes
at a mean of 14 months after osteotomy [30]. In the pre-
sent study, clinical evaluation was performed at 1 year after
osteotomy when routine plate removal, which was too early
to detect clinical difference between DTO and cOW-HTO.
The impact of DTO on clinical outcomes should be explored
prospectively and evaluated over longer periods.
There were some limitations to this study. First, arthro-
scopic finding of patellar cartilage was not enough clear to
be evaluated using ICRS grading with acceptable inter- and
intra-rater reliability. That is why the information about
Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1750–1756 1755
chondral lesions on the patellar side was not shown. Sec-
ond, the preoperative FTA and opening wedge size could
be significantly different between two groups because of our
patient selection for DTO depending on the preoperative
calculated correction angle. Third, also regarding to patient
selection, the DTO group included the patients with more
progressing PF OA compared to the cOW-HTO. Preopera-
tive proportion of each ICRS grade for the femoral troch-
lear was significantly different between two groups. Finally,
this study only evaluated the clinical outcome using JOA
score, not a specific assessment for PF joint, at 1 year after
osteotomy.
Conclusion
Performing DTO in OW-HTO has proven useful to main-
tain the preoperative patellar height, which contributed to
prevent progression of cartilage degeneration in the PF joint
after surgery. In respect of the biplanar osteotomy direction
in OW-HTO, the DTO, rather than cOWHTO, is the pre-
ferred technique for the treatment of varus knee OA to avoid
progression of PF cartilage degradation.
Compliance with ethical standards  wedge high tibial osteotomy may adversely affect the patellofemo-
Conflict of interest  The authors state that there are no conflicts of in-
terest, which might have influenced the preparation of this manuscript.
Funding  No financial support was provided to this study.
Ethical approval  Ethical approval was provided by the IRB of Omuta
Tenryo Hospital.
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