Arch Orthop Trauma Surg (2006) 126: 588–593
DOI 10.1007/s00402-006-0130-9
O R I GI N A L A R T IC L E
Suguru Ohsawa Æ Kazuya Hukuda Æ Yasuaki Inamori
Natsuo Yasui
High tibial osteotomy for osteoarthritis of the knee with varus deformity
utilizing the hemicallotasis method
Received: 22 March 2005 / Published online: 13 July 2006
Ó Springer-Verlag 2006
Abstract Introduction: A hemicallotasis method has been
developed utilizing an external fixator as high tibial os-
teotomy (HTO), and satisfactory results of this method
with the external fixator have been reported. This
external fixator has a universal joint that moves in all
directions. We have recently designed a hemicallotasis
device for this operation. Methods: HTO for the knee
with varus deformity utilizing the hemicallotasis method
was performed on 44 knees. The patients had a mean age
at operation of 65 years (range 49–82 years), a mean
follow-up period of 68 months (range 36–119 months),
and a mean preoperative knee score of 66 points (range
27–90 points). Results: The operated knees had a mean
knee score at the final follow-up of 86 points (range 51–
98 points), but the mean range of knee motion was not
changed as follows. Before surgery, the mean flexion was
129° (range 90–150°) and the mean extension was 5°
(range 30 to 0°), whereas at the final follow-up, the
corresponding values were 127° (range 85–150°) and 4°
(range 25 to 0°), respectively. Radiographically, the
femorotibial joint was classified as grade 2 in 9 knees,
grade 3 in 21 knees, and grade 4 in 14 knees according to
the classification of osteoarthritis (Kellgren and Lau-
rence). The patellofemoral joint was also classified as
grade 1 in 39 knees, grade 2 in 2 knees, and grade 3 in 3
knees. The mean femorotibial angle was 184° (4° varus)
before surgery, 169° (11° valgus) after pin extraction,
S. Ohsawa (&)
Department of Rehabilitation Medicine, Osaka Rosai Hospital,
1179-3, Nagasone-Cho, Sakai-Shi, 591-8025 Osaka, Japan
E-mail: sohsawa@orh.go.jp
Tel.: +81-722-523561
Fax: +81-722-505492
K. Hukuda Æ Y. Inamori
Department of Orthopaedic Surgery, NTT West Osaka Hospital,
2-6-40, Karasugatuji, Tennohji-Ku, 543-0042 Osaka, Japan
N. Yasui
Department of Orthopaedic Surgery, Tokushima University,
School of Medicine, 3-18-15, Kuramoto-Cho,
770-0042 Tokushima, Japan
and was maintained at the final follow-up. The compli-
cations of this method were relatively few and consisted
of pin-tract infection (8 knees), deep vein thrombosis (3
knees), and delayed union (2 knees). No peroneal nerve
palsy or compartment syndrome was encountered. No
knee was converted to total arthroplasty. However,
administration of analgesics was necessary in ten knees
at the final follow-up. Conclusion: The hemicallotasis
method easily determined the angle of correction even in
the knees with ligamentous laxity. Nevertheless, one of
the major demerits of this method was a longer period of
application of the external fixator. The level of evidence
was level IV (case series).
Keywords Osteoarthritis Æ Knee joint Æ
Hemicallotasis Æ Delayed union Æ Femorotibial angle
Introduction
Joint-preserving operation for osteoarthritis of the knee
with varus deformity has been established for many
years [9]. Many authors [4, 7] have reported excellent
results for high tibial osteotomy (HTO). However, the
conventional methods need fibular osteotomy or proxi-
mal tibiofibular joint release in addition to the postop-
erative difficulty to change the angle of correction.
Moreover, the correction angle is difficult to be deter-
mined when the joint is unstable. Insall et al. [7] pro-
posed that osteotomy was contraindicated in knees with
more than 15° of varus deformity. The major disad-
vantage of the conventional osteotomy is no way to
assess the mechanical axis postoperatively with full
weight bearing. To overcome these difficulties of the
conventional methods, Turi et al. [23] developed a
hemicallotasis method utilizing an external fixator as
HTO for varus deformity of the knee. Other authors
have also reported good short-term results [5, 12], using
the same external fixator. Magyer et al. [15] reported an
adequate result using the Garches model (Orthofix Srl.
Bussolengo, Italy), which was applied to the anterior

aspect of the tibia. The former device has a universal
joint, which moves in all directions. The latter model is
applied to the anterior aspect of the tibia, which inter-
feres to check callus formation from an anteroposterior
(AP) view. We have recently designed a hemicallotasis
device for this operation, and herein we report the
operative procedures and the results of our method. The
advantages of this device and hemicallotasis method are
discussed.
Materials and methods
From August 1991 to March 1998, we consecutively
operated on 55 knees with osteoarthritis of 40 patients
using the hemicallotasis method. The indication of this
method was medial compartmental osteoarthritis of the
knee with a relatively good range of motion (ROM)
(flexion: more than 100°). The mean age of the patients
at operation was 65 years (range 49–82 years). Three
patients (4 knees) died of unrelated diseases. Seven pa-
tients (7 knees) withdrew from the follow-up. We
examined 44 knees of 30 patients for a mean follow-up
period of 68 months (range 36–119 months). Bilateral
involvement was shown in 25 patients and unilateral
involvement in five patients. In bilateral involved pa-
tients, three knees had been treated with conventional
HTO and eight knees were treated conservatively. The
patients consisted of 23 women and 7 men. The mean
body mass index (BMI) at surgery was 26 kg/m2 (range
19.5–35.1 kg/m2). Clinical assessment was performed
according to the Hospital for Special Surgery (HSS)
rating system as reported by Insall et al. [8]. Radio-
graphic assessment of osteoarthritis of the knee was
based on the classification of Kellgren and Lawrence
[10]. In brief, the categories are grade 0: normal; grade 1:
minute osteophyte, doubtfully significant; grade 2: defi-
nite osteophyte, unimpaired joint space; grade 3: mod-
erate diminution of the joint space; and grade 4: joint
space greatly impaired with sclerosis of the subchondral
bone. The extent of deformity was determined from
weight-bearing radiographs and was recorded as the
femorotibial angle (FTA) according to the method de-
scribed by Bauer et al. [1] as follows. A straight line was
drawn along the axis of the femoral shaft to intersect a
corresponding line drawn through the tibial shaft, and
the lateral angle between these two lines was measured.
The level of evidence was level IV (case series).
Operative procedures
We planned preoperatively according to the AP radio-
graphs of the weight-bearing leg. A proximal pin was
inserted parallel to the tibial plateau 7 mm below the
joint line. Three to four centimeters below the medial
joint line, osteotomy was made on the medial side of the
tibia, and was extended upwards to the lateral cortex of
the tibia, 1.5 cm below the lateral knee joint line. The
589
mechanical axis of the leg was on 30–40% lateral from
the midpoint of the joint [6, 21] opening the medial os-
teotomy site with the lateral cortex as a hinge. This
preoperative planning calculated the length of callotasis
and the period of elongation. Under an image intensifier
and without air tourniquet, the posterior pin of the
proximal group of pins (‘‘the first pin’’) was initially
inserted parallel to the tibial plateau and the posterior
cortex of the plateau (Fig. 1c). The depth from the
plateau and from the posterior edge was approximately
7 mm each. Then, the pins of the distal part were in-
serted utilizing a template, and, two other pins of the
proximal group were inserted (Fig. 1). After all pins
were set, the medial cortex of the tibia was osteotomized
with chisel at the middle of the tibial tuberosity leaving
the lateral cortex intact (Fig. 2). After checking that a
mild valgus stress opened the osteotomy site under an
image intensifier, the hemicallotasis device (Orthofix Srl.
Bussolengo, Italy) was applied (Fig. 1). The patients
were allowed to undergo full weight bearing postoper-
atively. After 2-week rest, hexagonal screws for the neck
and elongation (Fig. 1a, b) were loosened and hemical-
lotasis was started at a speed of 0.25 mm over 4–6 h.
During elongation, weight bearing on the leg was not
allowed. The longer the body of the external fixator, the
smaller the angle between the proximal pin and the axis
of the fixator (Fig. 2). When the mechanical axis of the
leg reached 30–40% lateral from the midpoint of the
joint in the AP radiographs taken in the standing posi-
Fig. 1 The hemicallotasis device and pins are inserted into the
tibia. The device has two-axis free movement: one axis is neck
tilting (A screw for neck movement) and the other is elongation (B
screw for elongation). C A posterior pin of the proximal group of
pins, ‘‘the first pin’’ to be inserted
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Fig. 2 Case 22: a 49-year-old female suffering from osteoarthritis
of both knees. The change in the lower limb axis is shown.
Radiographs in the standing position before surgery (a
FTA=183°), immediately after the operation (b). Two or three
proximal and distal pins were inserted. Hemicallotasis was
completed (c FTA=169°). d After pin removal. Note that the
weight-bearing axis was moved to the lateral plateau. The fixator
was applied for 145 days
tion (Fig. 2c), the fixator was fixed and full weight
bearing was allowed. When the callus was mature,
loosening of the hexagonal screw started dynamization.
Full weight bearing was allowed to check the mechanical
axis in the plain radiographs, which did not change after
1–2 weeks. The fixator was then taken off, and another 1
or 2-week period elapsed before pin removal. After
checking for the absence of change in the mechanical
axis, all of the inserted pins were removed (Fig. 2d). We
made radiograph examination of the leg about 10 times
before pin removal.
The appropriate statistical procedures were per-
formed by a computer using StatView 5.0 (SAS Institute
Inc., Cary, NC, USA). The statistical significance of
differences in the mean values was computed with the
unpaired Student t test and Mann–Whitney U test. The
level of statistical significance was set at a P value of less
than 0.05, two-tailed. All of the predictor variables were
used in the logistic regression model as dependent vari-
ables. The model was simplified in a stepwise fashion by
removing the variables with P value of greater than 0.05.
Multiple regression analysis was used for studying the
factors influencing the period of fixator application, and
this was simplified in the same way as described in the
logistic regression model.
Results
Clinical results
The mean HSS knee score was 66 points (range 27–90
points) preoperatively, and 86 points (range 51–98
points) at the final follow-up. The knees of severe OA
had poorer results than that of moderate OA (grade 4,
79.6±13.2 points; grade 2, 3, 89.0±10.8 points,
P=0.0208). The mean preoperative ROM was 129°
(range 90–150°) in flexion and 5° (range 30 to 0°) in
extension. The mean ROM at the final follow-up was
127° (range 85–150°), and 4° (range 25 to 0°),
respectively. No knee was converted to total knee
arthroplasty (TKA) at the final follow-up. However, it
was necessary to administer nonsteroidal anti-inflam-
matory drugs for ten joints to suppress pain at the final
follow-up.
The postoperative complications consisted of pin-
tract infection (8 knees), deep vein thrombosis (3
knees), and delayed union (2 knees). One case needed
bone grafting to facilitate bone union. In another case,
joint fluid was excreted from ‘‘the first pin’’ that was
believed to invade the posterior side of the knee joint
cavity through the tibial plateau. The pin tract se-
creted joint fluid for 2 months, but it was cured
uneventfully. Pin-tract infection was treated by wash-
ing with saline containing antibiotics, and cured
uneventfully. This complication usually occurred in the
‘‘first pin’’. Neither peroneal nerve palsy nor com-
partment syndrome was encountered. The proximal
and distal tibiofibular joints were symptom free during
and after elongation.
Radiographical results
According to the classification of osteoarthritis [10], the
femorotibial joints were classified into grade 1 (0 knee),
grade 2 (9 knees), grade 3 (21 knees), and grade 4 (14
knees). The patellofemoral joints were also classified
into grade 1 (39 knees), grade 2 (2 knees), and grade 3 (3
knees). The mean FTA was 184° (range 172–197°) pre-
operatively, 169° (range 164–174°) at removal of the pins
and external fixator, 169° (range 164–174°) at 1 year
after surgery, and 169° (range 165–174°) at the final
follow-up, except for two patients with delayed union.
The mean correction angle was 15.3° (range 3–31°). The
FTA of delayed union cases was 180 and 182° at the
final follow-up.
Fracture of the lateral cortex of the tibia was one of
the serious problems in the hemicallotasis method, be-
cause this method requires an intact lateral cortex as a
fulcrum (Fig. 2). When the lateral cortex was fractured,
the proximal fragment was displaced and bone healing
was delayed (Fig. 3). We performed ten osteotomies on
patients with fracture of the tibial lateral cortex and
displacement of the proximal fragment. No fracture was
identified in the other 34 knees. Logistic regression

Fig. 3 Case 4: an 81-year-old male with osteoarthritis of both
knees. Lateral cortex fracture and proximal fragment transposition
occurred during hemicallotasis (a 2 weeks after starting the
elongation). Three months after completing the elongation with
insufficient FTA correction (b from 178 to 173°)
analysis revealed the factors influencing the fracture and
dislocation of the proximal fragment. A logistic model
for predicting the lateral cortex fracture was constructed
by using all the clinical and radiological factors, as well
as, the age, BMI, sex, body weight, FTA, and the level of
osteotomy, as described previously. This model was re-
fined by including only the fine predictors; namely, the
level of osteotomy (P=0.0020, 95% confidence interval;
3.6–318), preoperative FTA (P=0.207), FTA at pin
removal (P=0.741), and FTA at 1 year after surgery
(P=0.663). When transposition of the proximal frag-
ment occurred, the mean FTA at pin removal (169°) had
a correction loss at 1 year after surgery (171°) and at the
final follow-up (171°).
Recurrence of deformity
A graphical assessment by sequential plotting of FTA of
each knee revealed that recurrence of the varus defor-
mity was minimal (Fig. 4). The mean FTA (± SD) was
184° (±5.4) preoperatively, 169° (±2.4) at pin removal,
169° (±3.1) at 1 year after surgery, and 170° (±3.8) at
the final follow-up. In our middle-term follow-up series,
FTA of most cases was unchanged as shown in the
graph (Fig. 4). The changes of FTA at immediate pin
extraction and at the final follow-up were minimal. FTA
591
Fig. 4 Chronological changes of FTA in each knee. Pre preoper-
ative FTA, post at pin removal, numbers postoperative years
change of more than 5° was found in four legs. Three of
them had a fracture of the lateral cortex of the tibia, and
two of them were complicated with delayed union.
Period of fixator application
One of the problems of this method was long-term
application of the fixator (128 days on average), which
forced the patients to abstain from bathing for a long
period and caused a higher risk of pin-tract infection.
Lower level osteotomy tended to fracture the lateral
cortex, and transposition of the proximal fragment oc-
curred as mentioned above. The period of external fix-
ator application (mean ± SD) with transposition of the
proximal fragment (194±56 days) was significantly
(P<0.0001) longer than that without transposition
(108±34 days). Multiple regression analysis (R2=0.655)
revealed that the factors influencing the period of fixator
application were the final FTA (P=0.042, t=0.212) and
lateral cortex fracture (P<0.0001, t=5.15). The age
(P=0.563, t= 0.585), preoperative FTA (P=0.815,
t=0.237), and FTA at 1 year after surgery (P=0.570,
t= 0.574) showed no significant correlations. We
changed the operative procedure to use an image
intensifier for determination of the proper osteotomy
level. Disease severity and the period of fixator appli-
cation were also related to each other. The knees with
severe OA (grade 4) had longer period of application
(166±67 days) than that of the knees with moderate OA
(grade 2, 3, 112±38 days, P=0.0016).
Discussion
The advantages of hemicallotasis are postoperative
correction of the osteotomy angle and determination of
592
the correction angle under the weight-bearing condition.
When the knee was unstable due to ligamentous and
capsular laxity or subluxation of the femorotibial joint,
it was very difficult to determine the precise correction
angle preoperatively [7]. Some authors [2, 24] recom-
mended the use of a jig to assist in the accuracy and
reproducibility of the osteotomy cuts. Billings et al. [2]
recommended a newer jig and reported satisfactory
accuracy for the osteotomy cut. However, all these
methods could not determine the angle in the standing
position, and planning of osteotomy could not account
for the stability of the joints. Our method, however,
allowed easy determination of the angle postoperatively
and in the standing position even with full weight
bearing.
Another merit is low invasion to the knee joint. Our
method did not interfere with the knee joint, the
peroneal nerve or vessels, and there was no necessity
of fibular osteotomy or release of the proximal tibi-
ofibular joint. The extensor hallucis longus muscle is
innervated by a motor branch of the deep peroneal
nerve which mostly originates at 68–136 mm from the
point of the fibular head and runs close to the fibular
periosteum [11]. This anatomy explained the frequency
of the peroneal nerve damage by lateral side pin
insertion or by fibular bone cut. Charnley clamp, used
in the conventional method, needs trans-tibial pin
insertion. These pins caused weakness of the tibialis
anterior, the extensor hallucis longus, and the extensor
digitorum longus muscles, which were penetrated with
pins.
We did not encounter any compartment syndrome or
peroneal nerve palsy, because the pins were inserted only
in the medial side of the tibia. Nakamura et al. [18]
reported the incongruence of the proximal tibiofibular
joint by our method. However, CT scanning of the
proximal tibiofibular joint in several patients (data no
shown) did not show any incongruence of the joint, and
no patient complained of pain in the proximal or distal
tibiofibular joints after the operation through the final
follow-up, either. The perioperative complications were
few. Only 8 of 220 pins were infected. Furthermore,
infection tended to occur in compromised hosts such as
patients with diabetes mellitus, edematous legs caused
by former tibial fractures, and with immunosuppressive
drugs administration. Catagni reported that HTO using
Ilizarov method was complicated by wire infection in
10% of cases. He considered it as a minor problem ra-
ther than a complication [3].
Rigid fixation by plating and screws for the osteoto-
my lowered the incidence of complications. Six compli-
cations in 69 knees (9%) occurred after releasing the
proximal tibiofibular joint, leaving the fibula intact [2].
Koshino et al. reported that in 299 HTOs using broad
plate, three fractures, nine delayed unions, two infec-
tions, and three peroneal palsies occurred. They stated
that the difficulty in plating and screwing was realign-
ment of the fragments after fixation during the postop-
erative course [13].
The hemicallotasis method is an osteoplastic ap-
proach to the proximal tibia, which allows conversion to
TKA more readily than the conventional HTO [17].
When the conventional osteotomy is applied in unilat-
eral involvement, the operated leg will be shorter than
the sound leg. Compression of the osteotomy site makes
the tibia shorter than its original length, and conse-
quently the trouser leg length should be different. We
experienced a man who had undergone unilateral con-
ventional HTO. He needed a shorter trouser leg on the
operated side to suit the operated leg length. The other
side was subjected to the hemicallotasis method. He was
pleased with the absence of change in the leg length by
our method, and without adjustment of the ipsilateral
trouser leg.
Insall et al. [8] reported that no favorable results were
observed in patients older than 60 years of age no matter
what the degree of correction was. They recommended
TKA instead of HTO for more than 60-year-old pa-
tients. However, Yasuda et al. [24] disagreed and re-
ported no difference in the knee score between patients
less than 70 years of age and those older than 70 years.
Our shortest time of fixator application was 75 days in a
70-year-old patient with a correction angle of 13°. Age
did not influence the lateral cortex fracture and trans-
position of the proximal fragment in the logistic
regression analysis, or the period of external fixator
application in the multiple regression analysis.
Recently, medial opening wedge HTO has been
developed [14, 19–21], which overcame the disadvan-
tages of lateral closed wedge osteotomy in several points.
There is no fibular cut and osteoplastic HTO, leading to
easy TKA revision. Nevertheless, opening of medial ti-
bia was made in one stage, i.e., a drastic change in the
osteotomy site occurred. Spahn [20] discussed medial
opening wedge osteotomy using plate and screws when
the medial side was opened. Tibial head fracture was one
of the serious complications of this method (18.2%). But
other series [14, 21] reported no complications as men-
tioned above. On the contrary, our gradual opening
resulted in no such fracture.
However, this procedure had several disadvantages.
The worst problem was the pin insertion period
(mean ± SD 128±53 days). This long period increased
the risk of pin-tract infection. Patients could not take a
bath for a long time. Of the factors causing this pro-
longed fixator application were the lateral tibial cortex
fracture and transposition of the proximal fragment
which commonly resulted from the lower level of oste-
otomy cut as shown in Results. Our method of osteot-
omy was changed from using an oscillating saw directly
to the tibia to using an osteotome under an image
intensifier as described in Results. Furthermore, the line
of osteotomy was made longer by cutting the tibia with
inclination toward the proximal lateral cortex through
the middle of the tibial tuberosity in the AP view (Fig. 2)
as described previously [22]. The period of fixator
application was shortened to 80–90 days (data not
shown) by the aforementioned improvement. No lateral

cortex fracture of the tibia was shown in a recent series.
We excluded severely diseased knee (grade 4) for the
method, where expected to have longer period of fixator
application and poorer results. On the contrary, the
plating and screw method required only 2 weeks of ab-
stain from bathing. This can be the most difficult point
in our method. Recurrence of the deformity was rare in
our cases as shown in Fig. 4. We believe that recurrence
was caused by early pin extraction as mentioned previ-
ously [3] and delayed union due to fracture of the lateral
tibial cortex.
Our method had no effect on the patellofemoral
joint, such as Maquet procedure [16]. Our results
showed that patellofemoral osteoarthritis diagnosed by
plain radiography did not correlate with the patello-
femoral pain during going up and down stairs.
Furthermore, a patient showed improvement of the
patellofemoral joint by our method. These results
might explain the unnecessity for ventralization in the
femorotibial medial compartment osteoarthritis
involving the patellofemoral joint.
Finally, our study had several limitations. Nonran-
domized trial without control shows level IV of the level
of evidence. However, our patients were consecutively
operated and no other operation except TKA was ap-
plied in the period of the study. We believe the advan-
tage of the procedure is obvious.
In summary, Turi et al. [23] invented hemicallotasis
as HTO for varusly deformed knee osteoarthritis. We
developed a new external fixator for this procedure. The
result of this method was acceptable in the short-term
radiological and clinical assessment. The most difficult
problem was the long-term application of the external
fixator. However, we believe that the merits of our new
method outweigh the aforementioned demerits.
Acknowledgement We are grateful to Mr. Nobuo Shirahashi for his
help in our statistical analysis.
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