Knee Surg Sports Traumatol Arthrosc (2012) 20:571–578
DOI 10.1007/s00167-011-1610-1
KNEE
Increase in posterior tibial slope would result in correction loss
in frontal plane after medial open-wedge high tibial osteotomy
Shigeki Asada • Masao Akagi • Shigeshi Mori •
Tetsunao Matsushita • Kazuki Hashimoto •
Chiaki Hamanishi
Received: 8 February 2011 / Accepted: 4 July 2011 / Published online: 20 July 2011
Ó Springer-Verlag 2011
Abstract
Purpose The purpose of this study was to clarify the
causes of the increase in the posterior tibial slope during
open-wedge high tibial osteotomy (HTO) and to investi-
gate whether its changes influenced the correction angle in
frontal plane.
Methods We retrospectively reviewed 20 patients (26
knees) treated with open-wedge HTO. They were divided
into the following two groups. Group A consisted of the
knees whose opening gaps were fixed using a spacer plate
having the trapezoidal block with a 2° posterior slope. In
Group B, anterior and posterior opening gaps were fixed
separately. The posterior tibial slope and the hip–knee–
ankle angle were measured based on CT data. The rela-
tionship between the correction rate in frontal plane and the
changes of posterior tibial slope was investigated.
Results Increase in the posterior tibial slope was
2.1 ± 2.5° in Group A and 0.2 ± 1.2° in Group B, which
showed a statistical difference (P = 0.02). The difference
between the hip–knee–ankle angles before and after oper-
ation was 5.2 ± 2.3° in Group A and 5.5 ± 2.5° in Group
B. The correction rate was statistically correlated with the
changes of posterior tibial slope (R = -0.55, P = 0.003).
Conclusion To avoid increase in the posterior tibial slope,
the trapezoidal block with a only 2° posterior slope in a
spacer plate was not sufficient, and it was necessary to fix
anterior and posterior gaps separately. The correction angle
in frontal plane had a trade-off relationship with the
S. Asada (&)
M. Akagi
S. Mori
T. Matsushita

K. Hashimoto
C. Hamanishi
Department of Orthopaedic Surgery, Faculty of Medicine,
Kinki University, 377-2 Ohno-Higashi, Osaka-Sayama City,
Osaka 589-8511, Japan
e-mail: asada@med.kindai.ac.jp
changes in posterior tibial slope. Thus, we thought that
increase in the posterior tibial slope might result in cor-
rection loss.
Level of evidence Therapeutic study, Retrospective com-
parative study, Level III.
Keywords Open-wedge high tibial osteotomy
Posterior
tibial slope
Computed tomography
Osteoarthritis
Introduction
High tibial osteotomy (HTO) is an established operative
procedure for correction of varus deformity in middle-aged
patients with unicompartmental osteoarthritis [1, 4, 6].
Medial open-wedge HTO offers numerous advantages over
the lateral closing wedge procedures [5, 8]. The most
notable advantages include the precision of intraoperative
angular correction, no fibular osteotomy risk to the pero-
neal nerve palsy, no leg shortening, and preservation of
bone stock [11, 15, 16, 21]. Open-wedge HTO procedure
was employed by Debeyre and colleagues in 1967 [7] and
has gained the most popularity in recent years.
However, HTO is designed primarily to correct frontal
plane deformities and may cause changes in the posterior
slope of the proximal tibia. Numerous studies have repor-
ted that the posterior tibial slope increases after open-
wedge HTO [5, 8, 15, 17]. The changes of posterior tibial
slope may influence biomechanics of the knee. Hernigou
et al. [10] suggest that the changes in posterior tibial slope
lead to instability and excessive tibial translation of the
sagittal plane and may cause progression of osteoarthritis.
Agneskirchner et al. [2] report that the increased posterior
tibial slope after open-wedge HTO results in anterior
translation of the tibial plateau, which leads to an anterior
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shift of the tibiofemoral contact area. Rodner et al. [18]
advocate that the increased posterior tibial slope in anterior
cruciate ligament-deficient knees treated with open-wedge
HTO redistributes pressure into the posterior tibial plateau,
and suggest that the undesired redistribution of contact
pressure may increase the rate of degeneration and
disability.
We hypothesized that increase in the posterior tibial
slope can result in correction loss in the frontal plane. In
this study, therefore, we observed the characteristic ana-
tomical features of virtual osteotomy surface by computed
tomography (CT), and the posterior tibial slope and the
hip–knee–ankle angle were accurately measured based on
CT data. Furthermore, we compared two surgical methods.
To our knowledge, the correlation between the changes of
posterior tibial slope and the degrees of correction angle is
unknown. The purpose of this study was to clarify the
causes of the increase in posterior tibial slope. In addition,
we investigated whether the changes of posterior tibial
slope in sagittal plane influenced the correction angle in
frontal plane.
Materials and methods
All patients agreed to participate in the study. The patient
consent procedure strictly involved disclosure, under-
standing, and voluntariness. The study protocol was noted
to accord with a criterion of the Institutional Review Board
in the Kinki University Hospital that the approval of the
committee is not needed. We reviewed 20 patients (26
knees) treated with open-wedge HTO between 2006 and
2009 (Table 1). The patients were 10 men and 10 women
at mean age of 42.8 ± 14.0 years (range, 22–65 years).
There were 11 right and 15 left knees; six cases were
bilateral. Based on the inclusion criteria, 19 knees of
medial osteoarthritis with varus deformity and seven of
spontaneous osteonecrosis of medial compartment with
varus malalignment were enrolled. The procedure com-
bined with mosaic plasty for cartilage treatment was
Table 1 Characteristics of
Variables period
subjects
Implant
The gap value of the used plate
mean, SD, (range)
Age (mean/range)
Patients/joints (no.)
Diagnosis (no. of joint)
Osteoarthritis
Osteonecrosis
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Knee Surg Sports Traumatol Arthrosc (2012) 20:571–578
performed in seven knees and with anterior cruciate liga-
ment reconstruction in two knees. The clinical diagnosis of
osteoarthritis of the knee was made based on American
College of Rheumatology criteria [3]. Rosenberg radiog-
raphy (45° flexion posteroanterior weight bearing) was
used to evaluate osteoarthritis [19]. Spontaneous osteone-
crosis of the knee was diagnosed using magnetic resonance
imaging (MRI) [24, 25]. The exclusion criteria consisted of
a genu valgus deformity, previous knee surgery, and
rheumatoid arthritis. There were no complications such as
intra-articular fracture, compartment syndrome, peroneal
nerve palsy, infection, and nonunion.
Surgical technique
The knees were divided into the following two groups by
surgical methods. In the time period between 2006 and
2008, all osteotomies were fixed with VS Osteotomy Plate
[Biomet, Parsippany, US] (n = 13, Group A). Between
2008 and 2009, all osteotomies were fixed with second-
generation interlocking Puddu plate [Arthrex, Naples, US]
and staples [Meira, Nagoya, Japan] (n = 13, Group B).
Medial incision below the joint line was performed to
expose the medial tibial head. The anserinus pes was
incised by an electrocautery. In fluoroscopy, a K-wire was
introduced along the oblique osteotomy line as orientation,
from the region 3 cm below the medial joint line to the top
of fibular head. Osteotomy was carried out by an oscillating
saw parallel to the K-wire. The proximal tibia was osteo-
tomized by wide chisels with leaving 5 mm of the lateral
cortex. The osteotomy surface was opened carefully by
triangle chisels with avoiding intra-articular fracture.
In Group A, the opening gap was fixed with VS Oste-
otomy Plate having the trapezoidal block with a 2° pos-
terior slope in order to adjust to the cutting edge of tibia.
The VS osteotomy plate was mounted in the anteromedial
aspect of the proximal tibia (Fig. 1). The mean gap value of
the used plate was 8.4 ± 2.3 mm (range: 5–12.5).
In Group B, the staples and the interlocking Puddu plate
were used, and anterior and posterior opening gaps were
Group A (n = 13) 2006–2008 Group B (n = 13) 2008–2009
VS osteotomy systemÒ (Dynafix) Opening wedge plate systemÒ
(Arthrex) ? staple
8.4 ± 2.3 mm (5.0–12.5) 8.2 ± 1.8 mm (5.0–10.0)
45.1/22–65 39.2/23–58
11/13 9/13
7 12
6 1
Knee Surg Sports Traumatol Arthrosc (2012) 20:571–578
Fig. 1 Anteroposterior radiographs showing the VS osteotomy plate
after medial open-wedge high tibial osteotomy (HTO) in Group A
(a) and the interlocking Puddu plate with a staple in Group B (b)
separately fixed to the preoperatively planned levels for
each patient. A staple was placed at the medial border of
the patellar tendon attachment, and the interlocking Puddu
plate was mounted most posteriorly at the anteromedial
aspect. The mean gap value of the used plate was
8.2 ± 1.8 mm (range: 5.0–10.0). There was no significant
difference in the mean gap values of the used plate between
the groups (Student’s t test: P = 0.85). In all cases, the
mean gap value of the used plate was 8.3 ± 2.0 mm
(range: 5.0–12.5). Seventy-six percent (20 of 26 knees) had
had plates with a small range from 7.5 to 10.0 mm gap
value although the gap value of the used plate varied from
5.0 to 12.5 mm depending on the individuals.
In cases of correction angles of more than 12.5°, the
autologous bone (iliac crest from the same side) was
grafted at opening gap. In cases of lower correction angles,
the bone substitutes (Osferion: b-TCP; Olympus, Tokyo,
Japan) were filled into the defect.
Preoperative radiologic planning and evaluation
The correction angle was planned using a long-standing
radiograph according to the method of Marti CB et al. [15].
If one-third of the thickness of the medial cartilage was
lost, the new mechanical axis was planned to pass lateral to
the center of the knee at the 10% position (where the 0%
position is at the center of the knee joint and the 100%
position is at the lateral border of the plateau). When two-
thirds were lost, the new mechanical axis was planned to
pass through the 20% position. If total cartilage loss was
present, the mechanical axis was planned to pass through
the 30% position.
573
Multislice CT scanning (Light Speed VCT; GE
Healthcare, Milwaukee, Wisconsin) was done with 1-mm-
thick slices of the knee, proximal femur, and distal tibia a
month before and after operation in all cases. Three-
dimensional preoperative planning software for total knee
arthroplasty (the 3-D template, Japan Medical Materials
Co., Osaka, Japan) was used for the angular measurement.
This software provided the operating windows of three
multiplanar reformation (MPR) viewers, including the
frontal, sagittal, and axial planes. The mechanical axis of
the femur in frontal plane was defined as a line from the
center of femoral head to the center on the epicondylar
axis. The lower extremity was verticalized and frontalized
using the mechanical axis of the femur and the epicondylar
axis, respectively. The mechanical axis of the tibia in
frontal plane was defined so that it passed from the center
of tibial eminentia to the center of the talar dome. The hip–
knee–ankle angle was measured as an angle between the
frontal mechanical axis of the femur and the tibia in the
frontal plane of the MPR image. The mechanical axis of
the tibia in sagittal plane was defined as a line from the
center of the tibial plateau to the center of the talar dome.
The posterior tibial slope was measured as an angle
between the sagittal mechanical axis of the tibia and an
anteroposterior line passing the center of the medial tibial
plateau.
The correction angle was planned using a long-standing
radiograph and a desired gap of the spacer plate was cal-
culated on MPR views based on preoperative CT data. In
Group A, a desired gap was calculated based on medial–
lateral length of the osteotomy surface, and a spacer of the
plate whose gap was close to the desired gap was selected. In
Group B, a desired gap was planned based on Song’s find-
ings [20]. Osteotomy surface is shown in Fig. 2. MPR views
of this surface consisted of the regions 3 cm below the
medial joint line to fibular head in the frontal plane, parallel
to the medial tibial plateau in the sagittal plane, and per-
pendicular to epicondylar axis in the axial plane (Fig. 2a).
Point A is the medial border of patellar tendon attachment,
Point B the most medial prominent of proximal tibia, Point C
the posterior edge of medial proximal tibia, and Point D the
most lateral edge of cutting surface. Theoretically, when
Point B (the most medial point) was opened to the level of a
desired gap in an ‘‘open-book’’ fashion with using Point D
(the most lateral point) as a hinge, the posterior tibial slope
might not be changed (Fig. 2b). If a desired gap was set to
Point B, a gap of Point A was calculated by dividing the
distance from Point D to Point A by the distance from Point
D to Point B. Similarly, a gap of point C was calculated by
dividing the distance from Point D to Point C by the distance
from Point D to Point B (Fig. 2c). Therefore, when a gap of
Point B was 100%, the gap of Point A averaged
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a
b S.A. and T.M.), repeating the measurements 10 times in
c B
100% C
82% A
63%
gap
D
0%
Fig. 2 a Virtual osteotomy surface in axial view at the region 3 cm
below the medial joint line to the fibular head. Point A medial border
of patellar tendon attachment, Point B most medial prominent of
proximal tibia, Point C posterior edge of medial proximal tibia, and
Point D most lateral edge of cutting surface. b When Point B (the
most medial point) is opened to the level of a desired gap in an open-
book fashion using Point D (the most lateral point) as a hinge, the
posterior tibial slope may not be changed. c When a gap of Point B is
100%, average gap of Point A is 63.0 ± 3.2% and Point C
82.4 ± 3.6%
63.0 ± 3.2% (range: 58.9–68.7%) and Point C 82.4 ± 3.6%
(range: 75.7–86.7%) in this series.
The posterior tibial slope of medial tibial plateau in the
sagittal plane and the hip–knee–ankle angle in the frontal
plane were measured using this software before and after
operation. For measurement based on CT data, the varus
angle of the knee was considered to be the hip–knee–ankle
angle instead of the femorotibial angle. This software
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Knee Surg Sports Traumatol Arthrosc (2012) 20:571–578
provides the values to one decimal place. Therefore, the
measured and calculated data were reported to one decimal
place as the results. The measurement accuracy was
assessed using the intraclass correlation coefficient (ICC).
Two observers (S.A. and T.M.) repeated the measurement
twice, and the mean of the four values was regarded as the
true one. One observer (S.A.), repeating the measurements
10 times in three subjects, assessed the intraobserver
variations of the measurements. The maximum intraob-
server difference in measurements was 0.4° in the posterior
tibial slope (the largest SD was 0.16) and was 0.7° in the
hip–knee–ankle angle (the largest SD was 0.32). ICC (1, 1)
was 0.98 (95% CI, 0.97–0.99) in the posterior tibial slope
and was 0.95 (95% CI, 0.90–0.98) in the hip–knee–ankle
angle for intraobserver reliability. Two observers (between
one subject, assessed the interobserver variations of the
measurements. The maximum interobserver difference was
less than 0.5° in the posterior tibial slope and was less than
0.9° in the hip–knee–ankle angle. ICC (2, 1) was 0.97 (95%
CI, 0.93–0.98) in the posterior tibial slope and was 0.94
(95% CI, 0.87–0.97) in the hip–knee–ankle angle for
interobserver reliability.
The obtained correction angle in the frontal plane was
considered to be a difference in hip–knee–ankle angle
before operation from that after operation. The desired
correction angle at operation was calculated based on the
gap value of the used plate and medial–lateral length of the
osteotomy surface in each patient. Bone loss in the medial
tibial cortex due to a surgical saw at operation was esti-
mated to be 1.2 mm in all cases. The correction rate was
defined as the probability of obtaining a desired correction
angle in the frontal plane. The relationship of the correction
rate with the difference between the posterior tibial slope
before and after operation was investigated.
Statistical analysis
All datasets were checked for normal distribution. The
measurement accuracy was evaluated with statistical
software (SPSS statistics 15; SPSS Japan Inc., Tokyo,
Japan) using the intraclass correlation coefficient (ICC).
Pairwise comparisons between the values before and after
operation were performed with statistical software using
Student’s t test. P values of less than 0.05 were considered
to be statistically significant. The correlation analyses
were used to investigate the relationship of the correction
rate with the difference between the posterior tibial slope
before and after operation, which were performed using
the electronic spreadsheet (Excel 2003, Microsoft Corp.).
Correlations were evaluated with statistical software SPSS
using the Pearson’s product–moment correlation coeffi-
cient test.
Knee Surg Sports Traumatol Arthrosc (2012) 20:571–578 575

15
Group A Group A
* Group B
**
* Group B
*

Hip knee ankle angle (°)

* N.S. 10
Posterior tibial slope (°)

** p=0.02
*
13.3
5.2 5.5
11.2 11.4 11.7 5
3.6 3.9
**
0
2.1 -1.5 -1.6
0.3 *p<0.0001
** N.S.
-5
Before After Difference
Before After Difference
Fig. 4 The hip–knee–ankle angle in Groups A (open square) and B
Fig. 3 The posterior tibial slope in Groups A (open square) and B (filled square). Left column hip–knee–ankle angle before operation,
(filled square). Left column posterior tibial slope before operation, Middle column hip–knee–ankle angle after operation, Right column
Middle column posterior tibial slope after operation, Right column difference between the hip–knee–ankle angle before and after
difference between the posterior tibial slope before and after operation. (*P \ 0.0001, ** not significant)
operation. For each box and whiskers plot, the top and bottom
borders of the box represent the 25th and 75th percentiles, respec-
tively, and the cross (?) in the box is the mean. The ends of whiskers
represent the minimum and maximum of all the data. (*not : Group A : Group B
significant, **P = 0.02)
The correction rate (%)

Results

In Group A, the mean posterior tibial slope was

11.2 ± 3.8° (range: 4.6–17.4°) and 13.3 ± 5.1° (range:
5.9–22.6) before and after operation, respectively. In Group
B, the mean slope was 11.4 ± 3.0° (range: 7.8–17.6°) and
11.7 ± 3.6° (range: 5.4–18.5°) before and after operation,
respectively (Fig. 3). The posterior tibial slope before R=-0.55
operation showed no statistically significant difference P=0.003

from that after operation in both the groups (n.s.). Further,
the difference in posterior tibial slope before operation
from that after operation was 2.1 ± 2.5° (range:
-2.7–6.1°) in Group A and 0.2 ± 1.2° (range: -1.8–1.7°)
in Group B, which showed a statistically significant dif-
ference between the groups (P = 0.02).
After operation, mean hip–knee–ankle angle significantly
increased from 3.6 ± 3.2° (range: 0–11.5°) of varus to -1.5 ±
1.7° (range: -3.9–1.0°) of varus (P \ 0.0001) in Group A,
and from 3.9 ± 2.0° (range: 0.3–6.9°) of varus to -1.6 ±
1.2° (range: -4–0.4°) of varus in Group B (P \ 0.0001)
(Fig. 4). The difference between the hip–knee–ankle angles
before and after operation was 5.2 ± 2.3° (range: 2.8–11.8°)
in Group A and 5.5 ± 2.3° (range: 2.1–9.3°) in Group B,
suggesting there was no significant difference between the
groups (n.s.).
The obtained correction angle in the frontal plane was
defined as the differences between the hip–knee–ankle
angles before and after operation. The desired correction
y = -4.6047x + 94.426
Difference of posterior tibial slope (degree)
Fig. 5 Scatter plots of the difference between the tibial posterior
slope before and after operation plotted against the correction rate in
all knees (open circle: Group A, filled circle: Group B). A line of the
best fit constructed by regression analysis is shown. In the Pearson’s
correlation test, the correction rate was significantly correlated with
the changes of posterior tibial slope after operation (R = -0.55,
P = 0.003, y = -4.6047x ? 94.426)
angle at operation was 6.1 ± 2.2° (range: 3.4–11.2°) in
Group A and 6.1 ± 2.2° (range: 3.4–8.6°) in Group B,
which showed no significant difference between the groups
(n.s.). The correction rate was 85.4 ± 18.6% (range:
57.6–120.1%) in Group A and 93.0 ± 14.6% (range:
76.8–118.1%) in Group B, suggesting no significant dif-
ference between the groups (n.s.).

123
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The correction rate was statistically correlated with the
difference between the posterior tibial slope before and after
operation in all knees (R = -0.55, P = 0.003, Fig. 5).
Discussion
The most important finding of the present study was to
clarify the causes of the increase in the posterior tibial
slope. It is necessary to achieve precisely the desired cor-
rection during open-wedge HTO.
Numerous studies have reported increase (approxi-
mately 2°–4°) in the posterior tibial slope after open-wedge
HTO [5, 8, 15, 17]. Undesired changes in the posterior
tibial slope may influence knee kinematics and stability [9,
15, 18]. Some methods to maintain the original posterior
tibial slope after open-wedge HTO have been developed.
Noyes et al. [17] suggest that the posterior slope may
increase if the anterior opening gap at the tibial tuberosity
is equal to the posteromedial gap. In addition, the anterior
opening gap should be about half of the posteromedial gap
to maintain the posterior slope. According to Song et al.
[20], the anterior gap at anteromedial cortex should be
fixed to be approximately 67% of the posterior gap at the
posteromedial corner of proximal tibia using CT naviga-
tion. According to Jacobi et al. [13], the two reference
K-wires is placed at the proximal and distal to the osteot-
omy of the tibia, and two K-wire should be kept parallel to
ensure maintenance of the original tibial slope during the
procedure [12, 13]. Marti et al. [15] suggest that incom-
plete osteotomy of the posterior cortex and inadequate
release of the posterior soft tissue aiming at avoiding the
risk of neurovascular injury may increase the posterior
tibial slope.
It is important to open the osteotomy surface symmet-
rically in order to maintain the posterior tibial slope after
medial open-wedge HTO. In other words, the osteotomy
surface should be opened in an ‘‘open-book’’ fashion in the
frontal plane, but not in the sagittal plane. The osteotomy
surface showed the characteristic anatomical features
(Fig. 2). Theoretically, if Point B (the most medial point)
was opened to the level of a desired gap in an open-book
fashion using Point D (the most lateral point) as a hinge,
the posterior tibial slope angle might not be changed. In
Group A, the opening gap was fixed with VS osteotomy
plate having a 2° posterior slope in order to adjust the
cutting edge of tibia, but the mean increase in posterior
tibial slope was approximately 2.1°. The plate having a
trapezoidal block with an only 2° posterior slope was not
able to sufficiently decrease the changes of posterior tibial
slope after open-wedge HTO. When a 10-mm gap was
opened at operation, approximately 5° posterior slope were
necessary in a trapezoidal block to maintain the posterior
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Knee Surg Sports Traumatol Arthrosc (2012) 20:571–578
tibial slope after operation (data not shown). In Group B,
the anterior and posterior opening gaps were fixed sepa-
rately to achieve the preoperatively planed values calcu-
lated based on each patient’s CT data, and the posterior
tibial slope was well maintained after operation. Therefore,
it was thought to be necessary that the anterior gap and
posterior gap were fixed separately to maintain the pos-
terior tibial slope.
It was important to select the appropriate location of the
spacer block plate for avoiding the correction loss and for
the increase in posterior tibial slope. The location where
the plate could be placed was the anteromedial cortex of
proximal tibia (Fig. 2 shows the location from Points A to
B). Hernigou et al. [10] report that the bone wedges should
be grafted in the most posterior region of the opened
osteotomy site to avoid correction loss and to increase the
posterior slope. However, if a desired gap is located not in
the most medial point (Point B), but in the most posterior
point (Point C), the correction loss cannot be prevented. VS
osteotomy system plate (Group A) could not be placed in
the region sufficiently close to the most medial point due to
its wide profile, and a spacer block of this plate would be
placed apart from the most medial point. Interlocking
Puddu spacer plate (Group B) having narrow profile could
be placed in the region close to the most medial point. Our
results showed that the correction rate was not significantly
different between Groups A and B. However, the correc-
tion loss would appear when the location of the spacer plate
separated from the most medial point.
Although the correction rate was not statistically different
between the groups, it was correlated with changes in the
posterior tibial slope. This indicated there was a trade-off
relationship between the correction in the frontal plane and
that in the sagittal plane. Wang et al. [23] report that oste-
otomy of the proximal tibia using the lateral location as a
cortical hinge during open-wedge HTO affects the changes
of posterior tibial slope less than that using the posterolateral
location as a cortical hinge. However, they cannot find the
correlation between the correction angle and the posterior
slope. In the present study, it seemed that shifting the location
of cortical hinge from the lateral to the posterolateral regions
led to the increase in posterior tibial slope. Therefore, the
increase in posterior tibial slope might result in correction
loss in the frontal plane.
The present study had several limitations. First, the
number of subjects was small. The posterior tibial slope
measured using a conventional radiographic technique
shows variations depending on rotations of the tibia in the
lateral view [8, 14]. Therefore, to secure the accuracy of
each measurement, CT scan was used. Although we had
informed the patients of the deleterious effects of radiation
exposure, radiation exposure by scan could provide various
harmful effects. Thus, we do not perform CT scan recently
Knee Surg Sports Traumatol Arthrosc (2012) 20:571–578
for preoperative planning or postoperative assessment.
Second, to fix anterior and posterior gaps separately, a
staple and the interlocking Puddu plate were used in this
case series. If open-wedge HTO was performed with the
implants that do not have spacer blocks (e.g., Tomofix
Plate, Synthes, Tokyo, Japan), the anterior and posterior
gaps can be set independently, the correction loss would
not appear consequently [22]. Third, CT scan for postop-
erative assessment was obtained a month after operation.
El-Azab et al. [8] report that changes in the posterior tibial
slope after open-wedge HTO become stable over time, by
comparing the changes immediately after operation and
those at the time of implant removal. Therefore, we thought
that the condition a month after operation would have been
maintained since then, and correction loss might not occur.
Forth, substantial differences in the amount of medial
opening between the patients may significantly influence
the measured data of the posterior tibial slope. To dem-
onstrate that the correction rate affects changes in the
slope, we should measure the slope in patients with the
same amount of medial opening. In this study, however,
the gap value of the used plate varied from 5.0 to 12.5 mm
depending on the individuals, while about 76% of all cases
ranged from 7.5 to 10.0 mm. The small range of distribu-
tion seems to lead our conclusion that the correction rate
affects changes in the slope. In the strict sense, it is nec-
essary to make further studies using cases with the plate of
an equal gap.
Increase in posterior tibial slope would result in
correction loss. Our findings may help us resolve the
uncertainties regarding to the correction loss in medial
open-wedge HTO.
Conclusions
The trapezoidal block of plate having an only 2° posterior
slope could not sufficiently decrease changes of the pos-
terior tibial slope. Therefore, it was necessary to fix the
anterior and posterior gaps separately. The security of
correction angle had a trade-off relationship with the
changes of posterior tibial slope after open-wedge HTO.
Therefore, the increase in posterior tibial slope might result
in correction loss in the frontal plane. It was required to
understand the characteristic anatomical features of oste-
otomy surface and to pay special attentions to the fixation
of opening gap during open-wedge HTO.
Ethical board review statement All patients agreed to participate
in the study. The patient consent procedure strictly involved disclo-
sure, understanding, and voluntariness. The study protocol was noted
to accord with a criterion of the Institutional Review Board in the
Kinki University Hospital that the approval of the committee is not
needed.
577
Conflict of interest All authors do not have any financial support
and any competing interest with regard to this manuscript.
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