The Effects of Valgus Medial Opening Wedge High Tibial

Osteotomy on Articular Cartilage Pressure of the Knee:

A Biomechanical Study

Jens Dominik Agneskirchner, M.D., Christof Hurschler, Ph.D., Christiane D. Wrann, D.V.M.,
and Philipp Lobenhoffer, M.D.

Purpose: The objective of this study was to quantify the effect of different loading axes and of a
valgus opening wedge high tibial osteotomy (HTO) on tibiofemoral cartilage pressure. Methods: Six
human knee specimens were tested with a load of 1000N in extension in a materials testing machine
using a specially designed fixture. Pressure in the medial and lateral joint compartment was recorded
using pressure-sensitive films. Different loading alignments (varus, straight, and valgus) were
simulated. A medial opening wedge HTO was performed adjusting the loading axis to slight valgus.
The first measurement was performed with intact medial collateral ligament (MCL). Then the MCL
was dissected gradually and the cartilage pressure again analyzed. Results: There was a significant
correlation of the load distribution with the position of the loading axis. The medial compartment was
predominantly loaded in the varus setting. The more lateral the loading line intersected the knee, the
more pressure was redistributed laterally. The opening wedge HTO without the MCL release resulted
in a significant increase of the pressure medially (P ⫽ .002). Only after a complete release of the
MCL was a significant decrease of pressure medially observed after opening wedge HTO (P ⫽ .003).
Conclusions: The position of the loading axis in the frontal plane has a strong effect on the
tibiofemoral cartilage pressure distribution of the knee. The medial compartment is predominantly
loaded in a varus knee; a neutral mechanical axis slightly loads the lateral more than the medial
compartment. In valgus alignment, the main load runs through the lateral compartment. Clinical
Relevance: A medial opening wedge HTO maintains high medial compartment pressure despite the
fact that the loading axis has been shifted into valgus. Only after complete release of the distal fibers
of the MCL does the opening wedge HTO produce a decompression of the medial joint compartment.
Key Words: Cartilage—Knee arthroplasty—Osteoarthritis—Osteotomy—Varus deformity.

T he main principle of osteotomies is to achieve a

transfer of loading from diseased, arthritic areas
of the joint to areas with relatively intact, healthy
cartilage. The aim of a valgus high tibial osteotomy
From the Department of Trauma and Reconstructive Surgery,
Henriettenstiftung Hannover (J.D.A., C.D.W., P.L.), Hannover,
Germany, and the Institute for Biomechanics and Biomaterials
(C.H.), Hannover Medical School, Hannover, Germany.
Supported by a grant from the Robert Mathys Foundation.
Address correspondence and reprint requests to Jens Dominik
Agneskirchner, M.D., Henriettenstiftung Hannover, Trauma and
Reconstructive Surgery, Marienstrasse 72-90, 30171 Hannover,
Germany. E-mail: jens@agneskirchner.com
© 2007 by the Arthroscopy Association of North America
0749-8063/07/2308-6630$32.00/0
doi:10.1016/j.arthro.2007.05.018
(HTO) in medial osteoarthritis of a varus knee is thus
a decompression of the degenerated medial compart-
ment, in order to decrease the pain and delay the
progress of cartilage degeneration.1-4 Such procedures
are performed on younger patients in an attempt to
delay the implantation of the first total knee arthro-
plasty.
Relatively good short- and mid-term results for this
procedure have been reported in the literature.5-7
However, favorable results seem to be strongly depen-
dent on a precise correction of the loading axis. Un-
dercorrection with persisting varus usually leads to
poor results; overcorrection into large valgus may
result in medial joint opening and rapid development
of lateral osteoarthritis.8 There is a consensus in the

852 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 8 (August), 2007: pp 852-861
 TIBIAL OSTEOTOMY AND CARTILAGE PRESSURE
literature that the loading axis in the varus malaligned
osteoarthritic knee should be shifted from the varus
into a slightly valgus axis.6,9 Different opinions are to
be found on the precise amount of the valgus align-
ment achieved postoperatively. Some authors take the
anatomic axis of the femur and tibia as reference and
recommend a valgus of 8° to 10° postoperatively10-12;
others focus on the mechanical axis of femur and tibia
and suggest 3° to 5° of valgus.6,13 These suggestions
are based on individual clinical experiences and ret-
rospective studies. In another study by Fujisawa
et al.,14 an arthroscopic evaluation of the tibiofemoral
cartilage before and after valgus HTO was performed
in 54 knees with a follow-up of 4 months to 6 years.
The results were correlated to the amount of axis
correction measured as the postoperative medial–lat-
eral position of the loading axis in relation to the tibial
plateau. The authors concluded that the best clinical
results can be expected if the postoperative loading
axis is somewhere in the range of 30% of the distance
from the midpoint of the knee to the lateral joint
border.14 From this and other clinical papers, it was
then concluded that in an ideal correction, the me-
chanical axis, which runs from the center of the hip to
the center of the ankle, should intersect the knee joint
line at 62%, as measured from the medial to the lateral
border of the knee at the level of the tibial pla-
teau.8,15,16
Apart from these clinical studies, and despite the
enormous increase of interest in osteotomies, surpris-
ingly few experimental data exist on the intra-articular
effect of such load-transferring osteotomies.
The purpose of the present study was twofold: first,
to investigate the influence of the location of the
mechanical loading axis and second the effect of a
valgus opening wedge HTO on the intra-articular car-
tilage pressure of the knee. Our first hypothesis was
that the position of the mechanical loading axis has a
strong impact on the cartilage pressure distribution of
the knee. The second hypothesis was that a medial
opening wedge osteotomy may influence the cartilage
pressure secondary to changes in the soft tissue ten-
sion of the medial collateral ligament (MCL), which
are caused by the osteotomy.
METHODS
Human Cadaveric Knees
Six fresh-frozen human cadaveric knees, cut mid-
way on the shafts of both the femur and the tibia, were
used in this study. The mean age of the donors was 62
853
years (range, 55-66), and all donors were men. The
joints were examined to assure that they had not been
injured and that they had not been operated on previ-
ously. Furthermore, radiographs were taken before
biomechanical testing to exclude joints with osteoar-
thritis. The anatomic lateral distal femoral angle and
medial proximal tibial angle were measured to assure
that all specimens were within the normal range.17
After defrosting at room temperature over the course
of 28 hours, the joints were dissected with removal of
the skin and all subcutaneous tissue. The joints were
opened through an anteromedial arthrotomy, and the
muscles of the quadriceps and the patella were re-
moved. The medial and lateral collateral as well as
the cruciate ligaments were left intact, as were the
posterior joint capsule and the popliteus. There were
no ligament instabilities and no meniscal lesions.
Evaluation of the cartilage revealed some damage in
the femoropatellar joints, but no significant lesions on
the tibiofemoral surfaces. Ten centimeters of the prox-
imal femur and distal tibia were freed from all soft
tissues, and the bone stumps were embedded in hol-
low metal shafts using a two-component polyurethane
casting resin (UREOL FC 53; Vantico GmbH, Wehr,
Germany).
Mechanical Testing System
The knees were tested in full extension in a mate-
rials testing machine (Minibionix 858; MTS Systems,
Minneapolis, MN) under axial loading (Fig 1). Load-
ing was applied according to the following protocol:
ramp over 100 seconds at 10 N/sec to 1,000 N, after
which 1,000 N was held in load-control for 20 sec-
onds, after which load was again ramped to 0 N. A
specially designed and constructed fixture was used to
simulate different loading situations of the lower leg
by varying the anatomic and mechanical alignment
angles of the distal femur and the proximal tibia,
respectively, as well as the offset created by the fem-
oral head (Figs 1 and 2). The fixture was constructed
to allow stepless adjustment of the rotation of the joint
space, as well as the medial–lateral load-offset. Axial
loading of an entire leg between the centers of the hip
and ankle joint was simulated by the fixture, which
was built to reproduce the missing parts of the femur
and tibia in an anatomic manner.17 Standardized axial
loading was applied to the joint with free adjustment
of the intersection of the loading axis with respect to
the knee joint line, which was adjusted to be horizon-
tally oriented. Load was applied from the femur to the
tibia, with the distal end of the tibia and the proximal
854 J. D. AGNESKIRCHNER ET AL.

varus (25%), neutral (50%), and two additional differ-

ent valgus alignments (62% and 75%).
Tibiofemoral Cartilage Pressure
A pressure-sensitive film (K-Scan; Tekscan, Bos-
ton, MA) was inserted into the medial and lateral
tibiofemoral joint (Fig 3). This system, which has
been established for dynamic force and contact pres-
sure analysis,18,19 allows for the separate recording of
various pressure parameters in both compartments si-
multaneously, measuring pressures at a range from 0.1
to 17.2 MPa with a resolution of 0.07 MPa. The films
are 0.1-mm thick, and are comprised of two measuring
fields with an area of 33 ⫻ 22 mm and a spatial
resolution of 0.1 mm. For protection of the sensor
films, a thin piece of Teflon foil (DuPont, Wilmington,
DE) was glued to both sides of the sensor. Before
insertion into the joints, the sensors were precondi-
tioned and calibrated in the mechanical testing system
(Minibionix 858, MTS Systems) according to a stan-
dardized protocol as suggested by the manufacturer.

FIGURE 1. Axial loading of cadaveric knee joint using a specially

designed fixture in a mechanical testing machine. The fixture
allowed unconstrained loading of the joints in extension. Different
loading alignment situations were simulated varying the offset of
the force vector and the mechanical and anatomical angles of femur
and tibia. A vertically projected laser beam (dotted line) was used
to visualize the respective loading axes.

end of the femur potted in cylinders attached to gim-

bal-mounted universal joints which allowed frontal-
and sagittal-plane movement but constrained axial ro-
tation.
Alignments of the applied loads were standardized
by using the intersection of the loading axis with the
knee joint line measured as its offset from the medial
margin of the plateau. Accurate positioning of the
load-line was determined by a vertical laser beam
translating the frontal plane alignment between the
proximal and distal universal-joints to the knee joint
(Fig 2). Zero percent varus alignment was defined as
an offset of 0% of the width of the tibia plateau from
FIGURE 2. Cadaveric knee specimen, mounted into the testing
the medial margin. Zero percent loading axis (0%) fixture. An external fixator was used to stabilize the opening wedge
varus alignment was first tested, followed by 25% osteotomy.
 TIBIAL OSTEOTOMY AND CARTILAGE PRESSURE
Insertion into the medial and lateral tibiofemoral joint
was carried out from anterior to posterior, with the
sensors being carefully pulled into the joint space on
top of the cartilage and the menisci (Fig 3) using an
inside-out meniscus suturing system (Arthrex, Naples,
FL). The sensors were fixed to the posterior and me-
dial–lateral joint capsule using strong braided sutures.
Care was taken to ensure that the sensors were seated
on the cartilage without wrinkles and that nearly all
parts of the medial and lateral tibial plateau and the
menisci were covered. In order to determine the rela-
tive location of the joint surface relative to the sensor,
the perimeter of the joint surfaces of both compart-
ments was palpated with a small blunt plastic rod, and
its location was recorded. Thus, the topographic asso-
ciation of all regions of the tibial plateau to the sensing
elements of the sensors was recorded before testing
was initiated. Contact force (CF; in N), contact area
(CA; in mm2), contact pressure (CP; in MPa), and
peak contact pressure (peakCP; in MPa), as well as the
topographic pressure distribution between the medial
and lateral tibiofemoral joint space, were continuously
recorded while the joints were loaded. For further
analysis, the averages of all the parameters which
were measured during the plateau phase of the loading
protocol (20 sec of 1,000 N), were calculated.
Osteotomy
A medial intraligamentous opening wedge valgus
HTO was carried out in a biplanar fashion according
to the technique published by the knee expert group of
the Arbeitsgemeinschaft fuer Osteosynthesefragen.4,20
FIGURE 3. Pressure sensitive films (K-Scan, Tekscan) were in-
serted into the medial and lateral tibiofemoral joint space for
measuring the articular cartilage contact pressure.
855
FIGURE 4. A valgus medial opening wedge osteotomy was per-
formed between the fibers of the medial collateral ligament. An
osteotomy spreader was inserted in order to keep the osteotomy
gap open.
Several flat chisels were sequentially driven into the
osteotomy gap, and the osteotomy was gradually
opened to 9 mm without altering the anterior–poste-
rior tibial slope (Fig 4). A standard external fixator
was applied to stabilize the osteotomy during the
loading. After the osteotomy was performed, the load-
ing axis was again set to the 62% valgus position, and
the loading protocol began once again.
During the first set of measurements, the distal fibers
of the superficial MCL spanning the osteotomy gap were
left intact. Subsequently, the anterior half of the fibers
was transected (MCL-rel. 50%), followed by a complete
release with transection of all of the fibers of the MCL at
the level of the osteotomy (MCL-rel. 100%).
Statistical Analysis
Statistical comparisons were performed using the
non-parametric Wilcoxon test to compare means of
the different dependent variables between the experi-
mental groups at a significance level of ␣ ⫽ 0.05.
RESULTS
Influence of Frontal Plane Weight Bearing Axis
on Tibiofemoral Cartilage Pressure
Contact Pressure: In the medial tibiofemoral
compartment, CP varied between 0.52 (⫾0.25) MPa
(valgus 75%) and 0.94 (⫾0.44) MPa (varus 0%; Table
1). In the lateral compartment, the mean CP was
measured to be 0.50 (⫾0.16) MPa in varus (0%) and
0.88 (⫾0.27) MPa in valgus (75%). There was a
856 J. D. AGNESKIRCHNER ET AL.

TABLE 1. Mean Contact Pressure (MPa) in Medial and Lateral Tibiofemoral Joint Compartment During 1,000 N Axial
Load Related to Loading Axis
Location of Loading Axis Related CP Medial Compartment CP Lateral Compartment
Loading Alignment to Joint Line (Mean ⫾ SD; MPa) (Mean ⫾ SD; MPa)

Varus 0% 0.94 (⫾0.44) 0.50 (⫾0.16)

Varus 25% 0.61 (⫾0.26) 0.81 (⫾0.31)
Neutral 50% 0.71 (⫾0.35) 0.83 (⫾0.38)
Valgus 62% 0.6 (⫾0.33) 0.81 (⫾0.37)
Valgus 75% 0.52 (⫾0.25) 0.88 (⫾0.27)
Open Wedge HTO MCL Intact 62% 1.28 (⫾0.69) 0.51 (⫾0.04)
Open Wedge HTO MCL Release 50% 62% 0.84 (⫾0.5) 0.57 (⫾0.14)
Open Wedge HTO MCL Release 100% 62% 0.56 (⫾0.19) 0.73 (⫾0.27)

Abbreviations: CP, contact pressure; HTO, high tibial osteotomy; MCL, medial collateral ligament; SD, standard deviation.

strong correlation between the position of the loading
axis related to the knee joint line and the distribution
of contact pressure in the medial and lateral joint
compartments. The more lateral the weight-bearing
line intersected the joint line, the lower the medial and
the higher the lateral CP observed.
Contact Area: An average of 751 to 827 mm2 of
CA between the joint surfaces of the medial and
lateral femoral condyles with the tibial plateau was
measured while the joints were loaded with an axial
load of 1,000 N (Table 2). In contrast to the CP data,
no correlation was observed between the different
weight-bearing axes and the CA. In almost all loading
situations, the CA in the lateral compartment was
slightly larger than in the medial compartment.
Peak Contact Pressure: Similar to the values of
the CP, there was a strong correlation between the
loading axis and the topographic distribution of the
peak CP (peakCP; Table 3) between the medial and
lateral joint compartment. Only in the 0% loading
situation (varus) there was more peakCP medially
than laterally; shifting the loading axis to neutral
(50%) and into valgus, the peakCP increased laterally
and decreased medially.
Influence of Opening Wedge Valgus HTO on
Tibiofemoral Cartilage Pressure
A medial opening wedge valgus HTO was per-
formed and opened to 9 mm. After setting the loading
axis again to slight valgus (62%), the joints were
loaded again and pressure parameters again recorded.
Contact Pressure: The mean medial compartment
pressure averaged 1.28 (⫾0.69) MPa and the lateral
averaged 0.51 (⫾0.04) MPa, despite the valgus posi-
tion of the loading axis (62%; Table 1). Compared to
the data before osteotomy but with the same 62%
loading axis, this increase of medial compartment
pressure was statistically significant (P ⫽ .002). The
two-step-release of the MCL resulted in a decrease of
the medial CP and an increase in the lateral CP.
Compared to the values before the ligament release,
this decrease of medial compartment pressure was
statistically significant (P ⫽ .003).

TABLE 2. Contact Area (mm2) in Medial and Lateral Tibiofemoral Joint Compartment During 1,000 N Axial Load
Related to Loading Axis
Location of Loading Axis CA Medial Compartment CA Lateral Compartment
Alignment Related to Joint Line (Mean ⫾ SD; mm2) (Mean ⫾ SD; mm2)

Varus 0% 393.7 (⫾71.7) 374.5 (⫾178.7)

Varus 25% 371.9 (⫾56.9) 454 (⫾193.1)
Neutral 50% 338.6 (⫾88.5) 459.4 (⫾121)
Valgus 62% 335.5 (⫾67.2) 491.1 (⫾149.3)
Valgus 75% 321.7 (⫾129.6) 429.3 (⫾169.1)
Open Wedge HTO MCL Intact 62% 413.9 (⫾66.4) 399.4 (⫾117.2)
Open Wedge HTO MCL Release 50% 62% 365.2 (⫾39.6) 455.9 (⫾148)
Open Wedge HTO MCL Release 100% 62% 320.5 (⫾96.7) 443.4 (⫾193.2)

Abbreviations: CA, contact area; HTO, high tibial osteotomy; MCL, medial collateral ligament; SD, standard deviation.
 TIBIAL OSTEOTOMY AND CARTILAGE PRESSURE 857

TABLE 3. Peak Contact Pressure (MPa) in Medial and Lateral Tibiofemoral Joint Compartment During 1,000 N Axial
Load Related to Loading Axis
Location of Loading Axis Peak CP Medial Compartment Peak CP Lateral Compartment
Alignment Related to Joint Line (Mean ⫾ SD; MPa) (Mean ⫾ SD; MPa)

Varus 0% 2.4 (⫾1.21) 1.6 (⫾0.49)

Varus 25% 1.47 (⫾0.48) 2.04 (⫾0.56)
Neutral 50% 1.72 (⫾0.81) 2.92 (⫾1.57)
Valgus 62% 1.43 (⫾0.85) 2.97 (⫾1.59)
Valgus 75% 1.29 (⫾0.79) 2.54 (⫾1.22)
Open Wedge HTO MCL Intact 62% 3.78 (⫾3.25) 1.35 (⫾0.52)
Open Wedge HTO MCL Release 50% 62% 2.74 (⫾3.28) 1.59 (⫾0.53)
Open Wedge HTO MCL Release 100% 62% 1.42 (⫾0.86) 2.23 (⫾1.05)

Abbreviations: CP, contact pressure; HTO, high tibial osteotomy; MCL, medial collateral ligament; SD, standard deviation.

Contact Area: There was no change in the tib- sure and increased the lateral pressure. Interestingly,
iofemoral CA after the osteotomy, compared to the when in the neutral position (50%, straight leg), some-
values before the HTO (Table 2). Furthermore, no what higher pressures were recorded laterally than
differences in the topographic analysis of the CA medially, which corresponds well with existing data.23
between the medial and lateral joint compartment In the valgus positions (62% and 75%), the lateral
were found. pressure values exceeded the medial pressure by 30%
Peak Contact Pressure: After the osteotomy with to 40% (Fig 5). Based on these data, it seems that in
intact MCL at 62% of valgus, the medial compartment the case of a neutral loading axis, the main portion of
peakCP was increased to 3.78 (⫾3.25) MPa in the
medial compartment compared to 1.43 (⫾0.85) mea-
sured at the same loading axis (62%) before the os-
teotomy (Table 3). With the complete release of the
MCL, the mean medial peakCP was decreased to 1.42
(⫾0.82) MPa. In the lateral compartment, a mean
peakCP of 1.35 (⫾0.52) MPa was measured before
the complete MCL-rel., and 2.23 (⫾1.05) MPa after
the complete MCL-rel. (100%).

DISCUSSION
Within the last several years, interest in valgus HTO
has been increasing, and we have advocated the open-
ing wedge technique based on its characteristically
stable and reliable nature.4,20-22 Surprisingly, there is
little information on the actual intra-articular effect of
an osteotomy, which is intended to shift the loading
axis in the frontal plane (varus–valgus).
Our first intent in the present study was to correlate
the amount of offset of the loading axis from the
center of the knee in the frontal plane to the cartilage
pressure of the tibiofemoral joint space.
We have found that by simulating a varus deformity
(0% offset of the loading axis with the medial border FIGURE 5. Topographic pressure distribution in the medial and
of the knee joint), the intra-articular pressure in the lateral tibiofemoral joint space during axial loading of 1,000 N
medial compartment exceeded that of the lateral com- with different loading alignments: in varus (0%), most of the
loading was in the medial joint space; in neutral loading (50%)
partment by approximately 45%. Gradually shifting there was slightly more lateral than medial loading; in valgus
the loading vector laterally decreased the medial pres- (62%), most of the loading was in the lateral joint compartment.
858 J. D. AGNESKIRCHNER ET AL.

FIGURE 6. Topographic pres-

sure distribution in the medial
and lateral tibiofemoral joint
space after valgus opening
wedge osteotomy with intact
medial collateral ligament (MCL)
and after successive MCL re-
lease. Despite the valgus load-
ing after HTO with intact MCL
most of the loading occurred
medially (above). Only after a
complete release of the MCL
the medial joint space was de-
compressed (below). The col-
ored bars indicate the absolute
contact pressure (MPa) in a re-
spective cartilage area.

the femorotibial load runs through the lateral compart-
ment. This seems to suggest that an overcorrection
into valgus would not be necessary for decompression
of the medial joint space in case of medial joint
overload, such as in a varus osteoarthritis, assuming
that the pressure distribution after an osteotomy is
identical to these experiments.
Because of the large numbers of osteotomies per-
formed, these results have a large clinical impact and
suggest that the postoperative loading axis in a valgus
HTO should be individually adjusted to the special
needs of the patient. In patients with only mild medial
joint osteoarthritis, an overcorrection into valgus might
not be necessary, whereas patients with advanced me-
dial degeneration and medial joint collapse probably
benefit from a more extensive axis correction into a
valgus alignment.
In the second part of the study, cartilage pressure
measurements were performed after a valgus opening
wedge HTO. The osteotomy was opened to 9 mm
without releasing the fibers of the MCL running across
the osteotomy. An alignment of 62% of valgus was
again tested after the osteotomy in order to simulate
the loading axis, which is mostly aimed at a patient
postoperatively.14 At first glance, the results were sur-
prising: the CP in the medial compartment after the
osteotomy was much higher than in the lateral joint
space and there was a high pressure peak in the middle
of the middle tibiofemoral joint surface (Fig 6). Com-
pared to the values before osteotomy, as the same
valgus loading axis (62%) was used, the pressure
distribution after the osteotomy was almost reversed,
which is not the desired result when performing the
procedure. In comparison to the data of the varus
loading axis (0%), no reduction of cartilage pressure
in the medial compartment was achieved by the os-
teotomy, despite the fact that the joints were loaded at
62% of valgus; on the contrary, the medial pressure
values were even higher than in the varus setting.
Successive dissection (MCL-rel. 50% and 100%) of
the fibers of the MCL then resulted in a significant
decrease of the overall CP and especially the pressure
in the medial compartment, whereas the pressure in
the lateral compartment was increased. After a com-
 TIBIAL OSTEOTOMY AND CARTILAGE PRESSURE
plete release of the MCL, the pressure values laterally
were again higher than medially, and the pressure
peak medially was decompressed (Figs 6 and 7).
These data suggest that in a medial opening wedge
valgus HTO, the opening of the osteotomy gap leads
to a mechanical lift of the medial part of the plateau
upwards, thus pressing it against the medial femoral
condyle. Because of the crossing fibers of the MCL,
the part of the tibia below the osteotomy is unable to
compensate, which leads to increased MCL tension. It
seems that this imbalanced medial ligament overten-
sioning results in a preloading of the MCL and the
creation of concomitant tibiofemoral joint pressure in
the medial compartment, which is created indepen-
dently of the position of the loading axis. This as-
sumption is supported by the experimental finding of
this study that during the spreading of the osteotomy,
an increase of the CP in the medial compartment was
recorded in the absence of axial loading. Most likely,
this MCL overtension–associated cartilage pressure
after an opening wedge HTO without MCL-release
superimposes the pressure distribution, which is re-
lated to the loading axis.
Looking at the literature, the only related study, by
Riegger-Krugh et al.,23 experimentally looked at the
effect of an osteotomy in the frontal plane on the
cartilage pressure. In this study, however, a lateral
closing wedge osteotomy technique was used for the
axis correction. To our knowledge, there is no pub-
lished data on the effect of a valgus osteotomy in a
medial opening wedge technique. The primary differ-
859
FIGURE 7. Mean contact pressure
(CP) in medial and lateral compart-
ment during axial loading, indicat-
ing the relationship between posi-
tion of the loading axis and the
topographic pressure distribution.
The more lateral the loading line
intersected the knee joint, the more
pressure was measured laterally,
and the less pressure medially. Val-
gus opening wedge osteotomy re-
sulted in a significant increase of
the medial contact pressure, which
was only decompressed after com-
plete release of the medial collat-
eral ligament (MCL).
ence between these two types of valgus osteotomy is
their respective influence upon the MCL. A lateral
closing wedge osteotomy probably has only a minor
effect on the MCL, whereas a medial opening wedge
procedure increases the strain of the superficial distal
part of the MCL, because the spreading of the osteot-
omy gap is carried out intraligamentously between the
two insertion points of this band. These data are
therefore the first to show the direct effect of a valgus
opening wedge HTO upon the tibiofemoral cartilage
pressure.
In a 1979 study by Fujisawa,14 it was found that the
best results after a valgus HTO can be expected in
patients whose postoperative loading axis crossed the
knee joint line 30% to 40% laterally to the joint center.
However, in that study, the sole parameter of the
postoperative evaluation was an arthroscopic assess-
ment of the joint cartilage after a follow-up time
between 4 months and 6 years. An analysis with
respect to postoperative clinical parameters such as
pain, swelling, effusion, or radiographs, was not per-
formed. To our knowledge, there is no other study in
which the outcome of a valgus HTO was directly
correlated to the amount of axis correction and the
postoperatively achieved loading axis.
There are other biomechanical studies in which the
tibiofemoral joint cartilage pressure was measured
with regard to different loading axes in the frontal
plane.23,24 However, these studies utilized a static
loading model with color-coded Fujifilms, which only
permit a snapshot analysis of the pressure, such that
860 J. D. AGNESKIRCHNER ET AL.
only one specific (maximum) time point of the intra-
articular pressure was measured, which may not nec-
essarily reflect the existing CP over a certain time span
of loading.25 In the present study, in contrast, the
pressure parameters were continuously recorded at 10
Hz, which allowed the calculation of an average of the
collected data during a specific time period. Moreover,
in the loading model by Riegger-Krugh et al.,23 a
rather constrained loading fixture was used, which did
not allow frontal and sagittal plane movements be-
tween the femurs and tibias of the tested knee joints,
and thus in contrast to the present study nearly elim-
inated reactive forces within the joints that are gener-
ated by ligament tension.26 In fact, the simulation of
physiologic loading conditions in cadaveric knee
joints is difficult, because muscular forces and dy-
namic moments of ligament tension are difficult to
simulate realistically. In our study, a specially de-
signed unconstrained loading fixture and dynamic
loading cycle was used to approximate the in vivo–
loading conditions as closely as possible. The variety
of anatomic parameters between the tested cadaveric
specimens, which complicated the standardization of
the loading conditions even further, was counteracted
by using the fixture with its freely adjustable settings
of the loading vector in all directions. Thus the offsets
both in the sagittal and frontal plane, which are cre-
ated in physiologic loading by the femoral neck re-
lated to the anatomical axis of the femur, could be
simulated, and a horizontal joint space could be main-
tained through all tested loading conditions.
CONCLUSIONS
The position of the loading axis in the frontal plane
has a strong effect on the tibiofemoral cartilage pres-
sure distribution of the knee. The medial compartment
is predominantly loaded in a varus knee, a neutral
mechanical axis slightly loads the lateral more than
the medial compartment, and in valgus alignment, the
main portion of the load runs through the lateral
compartment. Despite shifting, the loading axis into
valgus medial opening wedge osteotomy maintains
high medial compartment pressures. For effective de-
compression of the medial joint space, a complete
release of the distal fibers of the MCL is necessary
after valgus opening wedge HTO.
REFERENCES
1. Coventry MB. Osteotomy about the knee for degenerative and
rheumatoid arthritis. J Bone Joint Surg Am 1973;55:23-48.
2. Coventry MB. Upper tibial osteotomy for gonarthrosis. The
evolution of the operation in the last 18 years and long term
results. Orthop Clin North Am 1979;10:191-210.
3. Coventry MB. Proximal tibial osteotomy. Orthop Rev 1988;
17:456-458.
4. Lobenhoffer P, Agneskirchner JD. Improvements in surgical
technique of valgus high tibial osteotomy. Knee Surg Sports
Traumatol Arthrosc 2003;11:132-138.
5. Lootvoet L, Massinon A, Rossillon R, et al. [Upper tibial
osteotomy for gonarthrosis in genu varum. Apropos of a series
of 193 cases reviewed 6 to 10 years later.] Rev Chir Orthop
Reparatrice Appar Mot 1993;79:375-384.
6. Hernigou P, Medevielle D, Debeyre J, et al. Proximal tibial
osteotomy for osteoarthritis with varus deformity. A ten to
thirteen-year follow-up study. J Bone Joint Surg Am 1987;69:
332-354.
7. Odenbring S, Egund N, Knutson K, et al. Revision after
osteotomy for gonarthrosis. A 10-19-year follow-up of 314
cases. Acta Orthop Scand 1990;61:128-130.
8. Dugdale TW, Noyes FR, Styer D. Preoperative planning for
high tibial osteotomy. The effect of lateral tibiofemoral
separation and tibiofemoral length. Clin Orthop 1992;274:
248-264.
9. Goutallier D, Hernigou P, Medevielle D, et al. [Outcome at
more than 10 years of 93 tibial osteotomies for internal arthri-
tis in genu varum (or the predominant influence of the frontal
angular correction)]. Rev Chir Orthop Reparatrice Appar Mot
1986;72:101-113.
10. Engel GM, Lippert FG. Valgus tibial osteotomy: Avoiding the
pitfalls. Clin Orthop 1981;160:137-143.
11. Kettelkamp DB, Wenger DR, Chao EY, et al. Results of
proximal tibial osteotomy. The effects of tibiofemoral angle,
stance-phase flexion extension, and medial-plateau force.
J Bone Joint Surg Am 1976;58:952-960.
12. Koshino TT, Moril J, Wada H, et al. High tibial osteotomy
with fixation by a blade plate for medial compartment
osteoarthritis of the knee. Orthop Clin North Am 1989;20:
227-243.
13. Hernigou P, Ovadia H, Goutallier D. [Mathematical modelling
of open-wedge tibial osteotomy and correction tables.] Rev
Chir Orthop Reparatrice Appar Mot 1992;78:258-263.
14. 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;10:585-608.
15. Miniaci A, Ballmer FT, Ballmer PM, et al. Proximal tibial
osteotomy. A new fixation device. Clin Orthop 1989;246:250-
259.
16. Noyes FR, Barber SD, Simon R. High tibial osteotomy and
ligament reconstruction in varus angulated, anterior cruciate
ligament-deficient knees. A two- to seven-year follow-up
study. Am J Sports Med 1993;21:2-12.
17. Paley D. Normal lower limb alignment and joint orientation.
In: Paley D, ed. Principles of Deformity Correction. Berlin,
Heidelberg: Springer Verlag, 2002;1-17.
18. Stukenborg-Colsman C, Ostermeier S, Hurschler C, et al.
Tibiofemoral contact stress after total knee arthroplasty: Com-
parison of fixed and mobile-bearing inlay designs. Acta Orthop
Scand 2002;73:638-646.
19. Agneskirchner JD, Hurschler C, Stukenborg-Colsman C, et al.
Effect of high tibial flexion osteotomy on cartilage pressure and
joint kinematics: A biomechanical study in human cadaveric
knees. Arch Orthop Trauma Surg 2004;124:575-584.
20. Lobenhoffer P, De Simoni C, Staubli AE. Open wedge high-
tibial osteotomy with rigid plate fixation. Techniques in Knee
Surgery 2002;1:93-105.
21. Agneskirchner JD, Freiling D, Hurschler C, et al. Primary
stability of four different implants for opening wedge high
tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2006;
14:291-300.
 TIBIAL OSTEOTOMY AND CARTILAGE PRESSURE 861

22. Lobenhoffer P, Agneskirchner J, Zoch W. [Open valgus align-
ment osteotomy of the proximal tibia with fixation by medial
plate fixator.] Orthopade 2004;33:153-160.
23. Riegger-Krugh C, Gerhart TN, Powers WR, et al. Tibiofemo-
ral contact pressures in degenerative joint disease. Clin Orthop
1998;348:233-245.
24. McKellop HA, Sigholm G, Redfern FC, et al. The effect of
simulated fracture-angulations of the tibia on cartilage pres-
sures in the knee joint. J Bone Joint Surg Am 1991;73:1382-
1391.
25. Bachus KN, DeMarco AL, Judd KT, et al. Measuring contact
area, force, and pressure for bioengineering applications: Using
Fuji Film and TekScan systems. Med Eng Phys 2006;28:483-488.
26. Shelburne KB, Torry MR, Pandy MG. Contributions of muscles,
ligaments, and the ground-reaction force to tibiofemoral joint
loading during normal gait. J Orthop Res 2006;9:9.

Articles in Press
are now available at the Arthroscopy Web site
www.arthroscopyjournal.org

Visit the Web site today and sign up to receive e-mail alerts with
links to new Articles in Press, Tables of Contents as each
issue publishes, as well as Citation Alerts and Search Alerts.