Original Article| Volume 37, ISSUE 11, P3297-3306, November 2021

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Unstable Lateral Hinge Fracture or Occult Complete Osteotomy Adversely Affects Correction Accuracy in Open-Wedge High Tibial Osteotomy


      To verify whether lateral hinge fracture (LHF) affects correction accuracy in open-wedge high tibial osteotomy (OWHTO) and to identify the fracture characteristics responsible for inaccurate correction, including LHF type and hinge location.


      Patients undergoing OWHTO with locking plate fixation between 2010 and 2016 were retrospectively reviewed. Patients who did not have a minimum 2-year of follow-up or postoperative long-standing hip-to-ankle radiographs were excluded. Correction accuracy was assessed using the weight-bearing line ratio: 57% to 67%, planned correction; 50% to 70%, acceptable correction; otherwise, inappropriate correction. The association between LHF and correction accuracy was assessed using the χ2 test. To identify the fracture characteristics responsible for inaccurate correction, LHF type (stable type 1 and unstable types 2 and 3) and hinge location (shallow osteotomy, deep osteotomy, and occult complete osteotomy) were analyzed using ordinal logistic regression analysis, taking other related demographic and radiologic factors into account. Clinical outcomes according to LHF type were evaluated using the Hospital for Special Surgery scores.


      A total of 148 cases were included; 41 (27.7%) showed LHF: type 1, 32 cases; type 2, 7 cases; and type 3, 2 cases. Planned, acceptable, and inappropriate corrections were noted in 63 (42.6%), 36 (24.3%), and 48 (32.4%) cases, respectively. LHF had a significant association with correction accuracy (P = .010). Regarding fracture characteristics, unstable LHF and occult complete osteotomy were significant risk factors (P = .016 and P = .004, respectively). Specifically in cases of stable LHF, occult complete osteotomy adversely affected correction accuracy (P = .025). No difference was found in the final Hospital for Special Surgery scores according to LHF type (P = .816).


      LHF affected the accuracy of coronal alignment correction in OWHTO. Unstable LHF or occult complete osteotomy were risk factors for inaccurate correction. Even among stable LHFs, those with occult complete osteotomy could lead to inaccurate correction.

      Level of Evidence

      Level III, retrospective cohort study.
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        • Noyes F.R.
        • Goebel S.X.
        • West J.
        Opening wedge tibial osteotomy: The 3-triangle method to correct axial alignment and tibial slope.
        Am J Sports Med. 2005; 33: 378-387
        • 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: 85-94
        • Yoo M.-J.
        • Shin Y.-E.
        Open wedge high tibial osteotomy and combined arthroscopic surgery in severe medial osteoarthritis and varus malalignment: Minimum 5-year results.
        Knee Surg Relat Res. 2016; 28: 270-276
        • Nha K.-W.
        • Kim H.-J.
        • Ahn H.-S.
        • Lee D.-H.
        Change in posterior tibial slope after open-wedge and closed-wedge high tibial osteotomy: A meta-analysis.
        Am J Sports Med. 2016; 44: 3006-3013
        • Van den Bempt M.
        • Van Genechten W.
        • Claes T.
        • Claes S.
        How accurately does high tibial osteotomy correct the mechanical axis of an arthritic varus knee? A systematic review.
        Knee. 2016; 23: 925-935
        • Kim Y.T.
        • Choi J.Y.
        • Lee J.K.
        • Lee Y.M.
        • Kim J.I.
        Coronal tibiofemoral subluxation is a risk factor for postoperative overcorrection in high tibial osteotomy.
        Knee. 2019; 26: 832-837
        • Lee D.-H.
        • Park S.-C.
        • Park H.-J.
        • Han S.-B.
        Effect of soft tissue laxity of the knee joint on limb alignment correction in open-wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3704-3712
        • Lee D.K.
        • Wang J.H.
        • Won Y.
        • et al.
        Preoperative latent medial laxity and correction angle are crucial factors for overcorrection in medial open-wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 1411-1418
        • Park J.-G.
        • Kim J.-M.
        • Lee B.-S.
        • Lee S.-M.
        • Kwon O.-J.
        • Bin S.-I.
        Increased preoperative medial and lateral laxity is a predictor of overcorrection in open wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 3164-3172
        • Han S.-B.
        • Choi J.-H.
        • Mahajan A.
        • Shin Y.-S.
        Incidence and predictors of lateral hinge fractures following medial opening-wedge high tibial osteotomy using locking plate system: Better performance of computed tomography scans.
        J Arthroplasty. 2019; 34: 846-851
        • Lee B.-S.
        • Jo B.-K.
        • Bin S.-I.
        • Kim J.-M.
        • Lee C.-R.
        • Kwon Y.-H.
        Hinge fractures are underestimated on plain radiographs after open wedge proximal tibial osteotomy: Evaluation by computed tomography.
        Am J Sports Med. 2019; 47: 1370-1375
        • Lee O.-S.
        • Lee Y.S.
        Diagnostic value of computed tomography and risk factors for lateral hinge fracture in the open wedge high tibial osteotomy.
        Arthroscopy. 2018; 34: 1032-1043
        • Miniaci A.
        • Ballmer F.T.
        • Ballmer P.M.
        • Jakob R.P.
        Proximal tibial osteotomy. A new fixation device.
        Clin Orthop Relat Res. 1989; 246: 250-259
        • 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
        • Staubli A.E.
        • 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: B55-B62
        • Nakamura R.
        • Komatsu N.
        • Fujita K.
        • et al.
        Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy.
        Bone Joint J. 2017; 99-B: 1313-1318
        • Altman D.G.
        Practical statistics for medical research.
        CRC Press, Boca Raton, FL1990
        • Stanley J.C.
        • Robinson K.G.
        • Devitt B.M.
        • et al.
        Computer assisted alignment of opening wedge high tibial osteotomy provides limited improvement of radiographic outcomes compared to flouroscopic alignment.
        Knee. 2016; 23: 289-294
        • El-Azab H.M.
        • Morgenstern M.
        • Ahrens P.
        • Schuster T.
        • Imhoff A.B.
        • Lorenz S.G.F.
        Limb alignment after open-wedge high tibial osteotomy and its effect on the clinical outcome.
        Orthopedics. 2011; 34: e622-e628
        • Lee D.-H.
        • Han S.-B.
        • Oh K.-J.
        • et al.
        The weight-bearing scanogram technique provides better coronal limb alignment than the navigation technique in open high tibial osteotomy.
        Knee. 2014; 21: 451-455
        • Kim K.-I.
        • Kim G.B.
        • Kim H.J.
        • Lee S.H.
        • Yoon W.-K.
        Extra-articular lateral hinge fracture does not affect the outcomes in medial open-wedge high tibial osteotomy using a locked plate system.
        Arthroscopy. 2018; 34: 3246-3255
        • Meidinger G.
        • Imhoff A.B.
        • Paul J.
        • Kirchhoff C.
        • Sauerschnig M.
        • Hinterwimmer S.
        May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 333-339
        • Yacobucci G.N.
        • Cocking M.R.
        Union of medial opening-wedge high tibial osteotomy using a corticocancellous proximal tibial wedge allograft.
        Am J Sports Med. 2008; 36: 713-719
        • Ogawa H.
        • Matsumoto K.
        • Akiyama H.
        The prevention of a lateral hinge fracture as a complication of a medial opening wedge high tibial osteotomy: A case control study.
        Bone Joint J. 2017; 99-B: 887-893
        • Lee S.-S.
        • Nha K.-W.
        • Lee D.-H.
        Posterior cortical breakage leads to posterior tibial slope change in lateral hinge fracture following opening wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 698-706
        • Goshima K.
        • Sawaguchi T.
        • Shigemoto K.
        • et al.
        Large opening gaps, unstable hinge fractures, and osteotomy line below the safe zone cause delayed bone healing after open-wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 1291-1298
        • Lee S.-S.
        • Celik H.
        • Lee D.-H.
        Predictive factors for and detection of lateral hinge fractures following open wedge high tibial osteotomy: Plain radiography versus computed tomography.
        Arthroscopy. 2018; 34: 3073-3079
        • Iorio R.
        • Pagnottelli M.
        • Vadalà A.
        • et al.
        Open-wedge high tibial osteotomy: Comparison between manual and computer-assisted techniques.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 113-119
        • Han S.B.
        • Lee D.H.
        • Shetty G.M.
        • Chae D.J.
        • Song J.G.
        • Nha K.W.
        A “safe zone” in medial open-wedge high tibia osteotomy to prevent lateral cortex fracture.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 90-95