Analysis of the Efficacy of High Tibial Osteotomy in Treating Knee Osteoarthritis at Different Levels of Weight Bearing Line Correction

Analysis of the Efficacy of High Tibial Osteotomy in Treating Knee Osteoarthritis at Different Levels of Weight Bearing Line Correction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of the Efficacy of High Tibial Osteotomy in Treating Knee Osteoarthritis at Different Levels of Weight Bearing Line Correction Yisan Wang, Guorui Cao, Xiao Wang, Peizhao Wang, Xiaotao Shi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8621213/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective investigating the efficacy of medial open wedge high tibial osteotomy (MOWHTO) in treating medial compartment osteoarthritis of the knee under different levels of postoperative Weight bearing line (WBL) correction to identify the optimal lower limb alignment zone. Methods A retrospective analysis was conducted on the clinical data of 180 patients with medial compartment knee osteoarthritis treated by MOWHTO at our institution from April 2016 to November 2024. The degree of postoperative correction of the WBL was calculated using full-length radiographs of both lower limbs. Patients were categorized into three groups based on the degree of postoperative WBL correction: Group A (50–55%), Group B (55–60%), and Group C (60–65%). Measurements of hip-knee-ankle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), and posterior tibial slope angle (PTSA) were taken at preoperative and final postoperative follow-up.Data on knee range of motion (ROM), pain visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lysholm scores were collected at preoperative and final postoperative follow-up to evaluate clinical outcomes before and after the surgery and compare clinical results among the three patient groups. Results The average follow-up duration for the three groups was approximately 39 months, with no statistically significant differences (P > 0.05). The postoperative HKA and MPTA in the three groups were significantly higher than preoperative levels (P 0.05).At the final postoperative follow-up, ROM, VAS, WOMAC scores, and Lysholm scores were all significantly improved compared to preoperative levels (P < 0.001). Comparing the three groups, patients in Group B demonstrated the most favourable outcomes in ROM (P = 0.013), VAS (P = 0.010), WOMAC score (P < 0.001), and Lysholm score (P = 0.004), while patients in Group C had the worst outcomes for these parameters. These differences were statistically significant. There were no statistically significant differences in the postoperative thrombosis incidence or wound complication rates among the three groups (P > 0.05). Conclusion Correcting the WBL to within the 50–65% range can effectively improve knee function by optimizing the distribution of lower limb alignment. The procedure is considered safe. Among the three groups, Correcting the WBL to 55–60% yielded the most significant improvement in knee function, while the range of 50–55% produced the weakest effect. High tibial osteotomy Weight bearing line Correction degree Knee osteoarthritis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Knee osteoarthritis (KOA) is a common degenerative disease of the knee joint, predominantly affecting middle-aged and elderly individuals. Its primary causes originate from frequent use of the knee joint, chronic wear and tear, and uneven pressure distribution. Its key risk factors include genetics, age, osteoporosis, and obesity 1 . The main pathogenesis of KOA involves the activation of inflammatory pathways due to factors such as the loss of chondrocytes 2 . The primary symptoms of KOA include pain, stiffness, and impaired joint function. Without timely intervention, it can significantly impact patients' quality of life, leading to muscle atrophy, reduced physical activity, poor sleep quality, and even adverse outcomes such as disability and depression 3 . Consequently, timely treatment of KOA to relieve pain and improve function is crucial for alleviating patient suffering. Treatment options for KOA primarily include oral medication, intra-articular injections, and surgical interventions. Surgical approaches mainly involve total or unilateral knee arthroplasty and osteotomy procedures 1 . Among these, osteotomy can effectively corrects lower limb alignment to substantially improve varus/valgus deformities. This technique can preserves the patient's natural knee structure while achieving symptomatic relief. For relatively younger patients requiring continued physical labour, osteotomy represents an effective surgical technique that maximizes the probability of achieving the desired therapeutic outcomes 4 . Medial knee osteoarthritis is the most common type of KOA. For patients with medial compartment osteoarthritis who are unresponsive to conservative management, medial open wedge high tibial osteotomy (MOWHTO) has become a well-established surgical technique with satisfactory clinical outcomes 5 . The primary objective of MOWHTO is to adjust the weight-bearing line (WBL). The degree of WBL correction (postoperative WBL percentage) is defined as the ratio of the line length connecting the intersection point of the weight-bearing line and the tibial plateau to the medial point of the tibial plateau, divided by the entire width of the tibial plateau. However, there remains no definitive consensus on the optimal percentage of postoperative WBL adjustment for maximizing functional recovery in patients with KOA. In 1979, Fujisawa et al. concluded through clinical research that correcting the postoperative WBL percentage to 62.5% most effectively promotes functional recovery 6 . For decades, this degree of correction has been consistently followed by orthopedic surgeons and is widely recognized as a relatively safe and effective postoperative correction target. In recent years, with the increasing volume of MOWHTO procedures, researchers have proposed different opinions through various perspectives. Amis et al. contended that the Fujisawa point represents an empirical standard derived from tradition, lacking rational validation through evidence-based science 7 . Martay et al., analysing from a biomechanical perspective, suggested that the safe range for the postoperative WBL percentage correction should lie between 50 and 65% 8 . Erdem et al. found through clinical studies that optimal clinical outcomes were achieved when patients were corrected to a postoperative WBL percentage range of 50–60% 9 . However, other studies have demonstrated that adjusting the postoperative WBL percentage to the 60–70% range yields the optimal clinical efficacy 10 , 11 . Therefore, the optimal degree of WBL correction for MOWHTO remains controversial, with no consensus reached. Identifying the optimal WBL correction level for MOWHTO holds significant clinical implications. This retrospective study aims to compare the clinical efficacy of MOWHTO treatment for medial knee osteoarthritis across different degrees of WBL correction, thereby providing clinicians and patients with more optimized and precise treatment options. Materials and Methods Inclusion and Exclusion Criteria Inclusion Criteria: 1. Patients with moderate-to-severe KOA (with knee varus), primarily involving medial knee osteoarthritis with pain, who have failed conservative treatment for over 6 months, and exhibit Kellgren-Lawrence grade 3 or 4 on X-ray. 2. Weight-bearing X-rays showing medial joint space narrowing, the angle of knee varus > 5°, an essentially normal lateral joint space, and generally intact knee joint structure; Magnetic resonance imaging(MRI) indicating intact knee ligaments, stable knee joint, and an absence of dislocation changes; 3. Patients with knee flexion-extension range of motion > 100°, varus angle < 30°, and flexion contracture < 10°; 4. Patients aged < 65 years. Exclusion criteria: 1. Patients with anterior cruciate ligament or collateral ligament injuries; 2. Patients with moderate-to-severe osteoarthritis in the patellofemoral or lateral compartments; 3. Patients with severe systemic medical conditions deemed intolerant to surgery following assessment; 4. Patients with active infection at the surgical site or systemic infection; 5. Patients with psychiatric disorders or those who are pregnant; 6. Patients with severe osteoporosis; 7. Patients with bone diseases caused by other conditions such as gout, rheumatoid arthritis, ankylosing spondylitis, or tumours; 8. Patients with peripheral pathology around the knee joint; 9. Patients who had undergone previous knee surgery or recent intra-articular injections. This study was reviewed and approved by the Medical Ethics Committee of Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital) (Approval No.: 2025KYKT0031-02). All patients provided informed consent and voluntarily participated in this study, signing an "Informed Consent Form". General Information This retrospective study screened 210 patients who underwent MOWHTO at our hospital's Knee Surgery Department between April 2016 and November 2024. Thirteen patients were excluded based on exclusion criteria. A further 11 patients were excluded due to incomplete imaging data or contact information preventing follow-up completion. During follow-up, six patients withdrew for personal reasons. Ultimately, 180 eligible patients were included. Postoperative full-length lower limb radiographs were obtained to calculate the degree of WBL correction using the following method: First, a line connecting the center of the femoral head to the center of the ankle joint was drawn, and the intersection of this line with the tibial plateau was identified. The distance from this intersection to the medial edge of the tibial plateau was designated as value a, while the total width of the tibial plateau (measured along the line connecting the medial and lateral edges) was designated as value b. The degree of correction was calculated as: Correction degree = a / b × 100% as illustrated in Fig. 1 . Patients were grouped based on the range of postoperative WBL correction: those with 50–55% correction constituted Group A, 55–60% Group B, and 60–65% Group C. Group A comprised 70 patients, Group B 51, and Group C 59. Treatment Approach Preoperative interventions: Upon admission, comprehensive examinations were conducted, including weight-bearing anteroposterior and lateral X-rays of both knees, full-length weight-bearing radiographs of both lower limbs, knee MRI, blood and urine routine tests, blood biochemistry, coagulation panel, liver and kidney function tests, inflammatory markers, electrocardiogram, chest X-ray, cardiac echocardiography, and bone density assessment. These tests confirmed surgical eligibility, ensured absence of significant underlying conditions, and excluded patients with severe osteoporosis. Surgical Approach: The patient was positioned supine. Following successful anaesthesia, arthroscopy was performed first. Two incisions of approximately 0.5 cm were made on the anteromedial and anterolateral aspects of the affected knee. The anterior-lateral approach was employed to insert the arthroscope to examine the meniscus and cartilage within the knee joint. Proliferative synovial tissue and loose cartilage fragments within the joint cavity were cleared. If meniscal damage was present, perform arthroscopic suturing or partial meniscectomy based on the location and severity of the damage. After the treament, stability was assessed using a probe. Hemostasis, irrigation, and closure of the incision were performed. Following arthroscopic exploration and initial management, a 7 cm oblique incision was made 2 cm medial to the tibial tubercle. Layers were dissected along anatomical planes, separating skin and subcutaneous tissue to identify the medial collateral ligament and pes anserinus. The deep insertion of the medial collateral ligament was dissected and transected. A Hoffman retractor was employed to protect the patellar tendon and neurovascular bundle. Two parallel Kirschner wires (K-wires) were inserted parallel to the superior border of the pes anserinus, directed toward the ipsilateral tibiofibular syndesmosis. The depth of the wires within the bone was measured. C-arm fluoroscopy was applied to monitor K-wire positioning. After adjusting the K-wires to the planned depth and angle, oblique and transverse osteotomies were performed using a reciprocating saw, preserving approximately 1 cm of the lateral hinge. Stacked bone saws were inserted sequentially to enlarge and refine the osteotomy plane. Position spreaders were used to maintain the angulation, inducing slight leg varus. The saws were removed and the angulation was temporarily stabilised with crossed K-wires. The alignment was re-assessed by intraoperative fluoroscopy, ensuring the force line passed through the center of the hip joint (typically the center of the femoral head) and the center of the ankle joint (normally the midpoint of the talus width). The alignment was adjusted under C-arm fluoroscopy guidance to traverse the slope of the lateral intercondylar crest. Once proper alignment correction was confirmed, The spread-open bone was secured with plates and screws. When the distraction gap exceeded 15 mm, artificial bone or autologous iliac bone was implanted. After reconfirming secure fixation with C-arm fluoroscopy, the incision was irrigated, a negative pressure drainage tube was placed in the wound, which was subsequently closed in layers, and the wound was closed in layers. The incision site was covered with gauze and the affected area bandaged with an elastic bandage. Postoperative Management Standard protocols for infection prevention, oedema reduction, analgesia, and anticoagulation were implemented postoperatively. Bed rest with elevation of the affected limb was prescribed to reduce swelling. The drainage tube was removed once the daily drainage volume fell below 50 ml per 24 hours. On the first postoperative day, the patient was instructed to perform ankle pump exercises and quadriceps muscle strengthening exercises in bed. On the second day, the patient was advised to bear partial weight with crutch support, continuing ankle pump exercises, knee flexion/extension movements, and quadriceps strengthening exercises. Sutures were removed at 2 weeks postoperatively. Full weight-bearing was permitted at 4–6 weeks, with normal activities resumed after 3 months. Observation Indicators Preoperative and final follow-up bilateral full-leg length measurements and weight-bearing anteroposterior/lateral knee radiographs were obtained. The hip-knee-ankle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), and posterior tibial slope angle (PTSA) were determined. Postoperative joint function and recovery were assessed using the range of motion (ROM), visual analogue scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and Lysholm knee score. Perioperative data (including operative time, postoperative thrombotic events, wound complications, etc.) were obtained to evaluate surgical safety. Statistical analysis Data were analysed using SPSS 27.0 software (IBM Corporation, USA). Quantitative data were expressed as mean ± standard deviation (‾x ± s), while categorical data were presented as counts/ratios. For intergroup comparisons, data normality and homogeneity of variance were assessed. If data met normality and homogeneity criteria, one-way analysis of variance was employed. Otherwise, the Kruskal-Wallis test was used. For pre- and postoperative comparisons, independent samples t-tests were applied to data meeting normality and homogeneity of variance criteria. Rank-sum tests (Kruskal-Wallis tests) were employed for non-normally distributed or heteroscedastic data. Categorical data comparisons utilised chi-square or Fisher's exact probability tests. P < 0.05 indicated statistically significant differences. The statistical methodology was reviewed by our hospital's statistical experts. Results General Characteristics There were no statistically significant differences in the mean follow-up duration among the three patient groups A to C (39.95 ± 6.49 months, 39.53 ± 6.69 months, 39.08 ± 6.64 months, respectively; P > 0.05). There were no significant differences in age, sex, height, weight, body mass index, or Kellgren-Lawrence classification among the three groups (P > 0.05). See Table 1 for details. Table 1 General Characteristics of Patients in the Three Groups Indicator Group A(n = 70) Group B(n = 51) Group C(n = 59) P Age (years) 55.41 ± 7.42 54.71 ± 5.04 54.37 ± 4.40 0.606 Gender (Male/Total, n) 46/70 23/51 26/59 0.929 Height (cm) 165.94 ± 6.31 165.26 ± 7.70 165.73 ± 6.67 0.891 Weight (kg) 67.69 ± 10.59 66.85 ± 9.97 66.69 ± 9.39 0.838 body mass index (BMI,Kg/m²) 24.56 ± 3.49 24.40 ± 2.63 24.21 ± 2.59 0.809 Operative Time (min) 78.57 ± 21.35 83.68 ± 21.89 80.42 ± 20.49 0.514 K-L Grade (Grade 3/Total, n) 50/70 32/51 40/59 0.612 Follow-up Duration (months) 39.95 ± 6.49 39.53 ± 6.69 39.08 ± 6.64 0.898 Preoperative Indicators There were no statistically significant differences in relevant angles or functional scores among the three groups of patients prior to surgery (P > 0.05) (Table 2 ). Table 2 Comparison of Preoperative Indicators Among the Three Groups of Patients Indicator Group A(n = 70) Group B(n = 51) Group C(n = 59) P HKA(°) 171.29 ± 2.72 172.97 ± 3.78 173.92 ± 5.29 0.277 MPTA(°) 83.85 ± 2.74 84.52 ± 4.78 85.59 ± 3.31 0.357 JLCA(°) 4.36 ± 4.21 2.74 ± 2.23 3.63 ± 5.81 0.230 PTSA(°) 8.44 ± 3.07 8.27 ± 2.86 7.51 ± 2.75 0.179 WOMAC (points) 156.64 ± 6.74 160.13 ± 6.35 158.95 ± 8.12 0.329 WOMAC Pain Score (points) 30.95 ± 2.89 31.07 ± 2.31 31.50 ± 2.69 0.717 WOMAC Stiffness Score (points) 13.82 ± 1.37 14.60 ± 1.24 14.05 ± 1.29 0.202 WOMAC Activity Score (points) 111.86 ± 6.11 114.47 ± 5.24 113.39 ± 7.12 0.469 Lysholm Score (points) 20.59 ± 5.03 21.47 ± 5.07 20.47 ± 4.93 0.802 Visual Analogue Scale (VAS) (points) 7.23 ± 0.922 7.40 ± 0.83 7.39 ± 0.82 0.739 ROM(°) 107.05 ± 5.91 109.00 ± 6.87 104.61 ± 4.98 0.126 Comparison of Pre- and Postoperative Indicators The postoperative HKA (180.67 ± 3.61 vs 172.59 ± 4.18) and MPTA (88.86 ± 6.80 vs 84.62 ± 3.52 ) increased significantly compared to preoperative levels (P < 0.001), while the JLCA (3.28 ± 1.77 vs 3.76 ± 4.59) decreased significantly (P < 0.001) (Table 3 ). The WOMAC scores (62.12 ± 28.92 vs 158.51 ± 7.42) and related scores, the VAS scores (1.69 ± 1.26 vs 7.35 ± 0.85), were significantly reduced (P < 0.001), the Lysholm scores (76.39 ± 14.09 vs 20.71 ± 4.93) and ROM (128.93 ± 13.91 vs 106.2 ± 5.86) were significantly increased (P < 0.001), while the PTSA showed no significant change from before to after surgery (8.59 ± 2.97 vs 8.07 ± 2.93, P = 0.645). Comparisons of imaging metrics and functional scores at baseline and final postoperative follow-up for all patients are presented in Table 3 . Table 3 Comparison of Preoperative and Postoperative Metrics for All Patients Indicator Preoperative(n = 180) Postoperative(n = 180) P HKA(°) 172.59 ± 4.18 180.67 ± 3.61 <0.001 MPTA(°) 84.62 ± 3.52 88.86 ± 6.80 <0.001 JLCA(°) 3.76 ± 4.59 3.28 ± 1.77 <0.001 PTSA(°) 8.07 ± 2.93 8.59 ± 2.97 0.645 WOMAC (points) 158.51 ± 7.42 62.12 ± 28.92 <0.001 WOMAC Pain Score (points) 31.25 ± 2.66 11.92 ± 5.22 <0.001 WOMAC Stiffness Score (points) 14.09 ± 1.32 5.81 ± 2.97 <0.001 WOMAC Activity Score (points) 113.16 ± 6.48 44.39 ± 21.46 <0.001 Lysholm Score (points) 20.71 ± 4.93 76.39 ± 14.09 <0.001 Visual Analogue Scale (VAS) (points) 7.35 ± 0.85 1.69 ± 1.26 <0.001 ROM(°) 106.2 ± 5.86 128.93 ± 13.91 <0.001 Postoperative Comparison Among the Three Patient Groups The postoperative HKA and MPTA scores in the three groups displayed a gradual increase with greater correction (P 0.05) (Table 4 ). The postoperative WOMAC scores among the three groups A–C (69.05 ± 23.19, 50.93 ± 29.06, 62.53 ± 31.12, respectively, P < 0.001), WOMAC pain scores (13.68 ± 4.91, 10.00 ± 5.39, 11.66 ± 5.15, respectively, P < 0.001), WOMAC stiffness score (6.73 ± 2.43, 4.93 ± 2.76, 5.63 ± 3.25, respectively, P < 0.001), WOMAC activity score (48.64 ± 16.75, 36.00 ± 21.59, 45.24 ± 23.35, respectively, P < 0.001), and VAS score (2.27 ± 1.35, 1.20 ± 0.94, 1.55 ± 1.22, P = 0.010) were lowest in Group B and highest in Group A. Additionally, the Lysholm scores (69.23 ± 16.86, 82.67 ± 7.09, 78.05 ± 12.95, respectively, P = 0.004), ROM (123.18 ± 14.84, 134.67 ± 8.76, 130.00 ± 14.09, respectively, P = 0.013) were optimal in Group B, followed by Group C, with Group A displaying the poorest outcomes, demonstrating statistically significant differences. Detailed comparisons of outcome measures across the three groups are presented in Table 4 . Table 4 Comparison of Outcome Measures Among the Three Groups (P values for pairwise comparisons between Group A and Group B, Group A and Group C, and Group B and Group C are denoted as P1, P2, and P3, respectively) Indicator Group A(n = 70) GroupB(n = 51) Group C(n = 59) P P1 P2 P3 HKA(°) 178.65 ± 2.51 180.75 ± 3.23 183.03 ± 3.51 <0.001 0.001 <0.001 <0.001 MPTA(°) 86.96 ± 6.58 90.17 ± 5.72 90.35 ± 7.18 0.008 0.022 0.004 0.901 JLCA(°) 3.02 ± 1.49 3.22 ± 2.17 3.62 ± 1.78 0.149 0.591 0.053 0.283 PTSA(°) 8.99 ± 2.96 8.72 ± 3.37 8.05 ± 2.66 0.188 0.649 0.071 0.295 WOMAC (points) 69.05 ± 23.19 50.93 ± 29.06 62.53 ± 31.12 <0.001 <0.001 <0.001 <0.001 WOMAC Pain Score (points) 13.68 ± 4.91 10.00 ± 5.39 11.66 ± 5.15 <0.001 <0.001 0.293 0.035 WOMAC Stiffness Score (points) 6.73 ± 2.43 4.93 ± 2.76 5.63 ± 3.25 <0.001 <0.001 0.439 <0.001 WOMAC Activity Score (points) 48.64 ± 16.75 36.00 ± 21.59 45.24 ± 23.35 <0.001 <0.001 0.159 <0.001 Lysholm Score (points) 69.23 ± 16.86 82.67 ± 7.09 78.05 ± 12.95 0.004 0.016 0.262 0.004 Visual Analogue Scale (VAS) (points) 2.27 ± 1.35 1.20 ± 0.94 1.55 ± 1.22 0.010 0.030 0.344 0.010 ROM(°) 123.18 ± 14.84 134.67 ± 8.76 130.00 ± 14.09 0.013 0.063 0.259 0.013 Safety Assessment Results No statistically significant differences were observed in the incidence of thrombotic or wound complications among the three groups (P > 0.05) (Table 5 ). Table 5 Postoperative Safety Assessment Indicators for the Three Patient Groups Indicator Group A(n = 70) Group B(n = 51) Group C(n = 59) P Number of postoperative wound complications (incidence rate) 3(4.29%) 3(5.88%) 3(5.08%) 0.168 Number of postoperative thrombosis cases (incidence rate) 3(4.29%) 1(1.96%) 2(3.39%) 0.490 Typical Cases Case 1 (Group A): A 61-year-old female patient with medial compartment osteoarthritis of the left knee. At admission, the patient’s knee WOMAC score was 150, Lysholm score 28, VAS score 8, and knee ROM 115°. The patient underwent arthroscopic meniscectomy and MOWHTO. Postoperatively, the WBL percentage was corrected to 51.04%. At the final follow-up, the WOMAC score was 66, Lysholm score 74, VAS score 3, and knee ROM 140°. Pre- and postoperative imaging findings and functional status at the final follow-up are presented in Figs. 2 and 3 . Case 2 (Group B) involved a 60-year-old female patient with medial compartment osteoarthritis of the right knee. At admission, the knee WOMAC score was 164, Lysholm score 14, VAS score 6, and knee ROM 120°. Postoperatively, the WBL percentage was corrected to 56.35%. At the final follow-up, the WOMAC score was 48, Lysholm score was 85, VAS score 2, and knee ROM 130°. Pre- and postoperative imaging findings are shown in Fig. 4 . Case 3 (Group C): A 56-year-old male patient with medial compartment osteoarthritis of the right knee. At admission, the knee WOMAC score was 160, Lysholm score 28, VAS score 7, and knee ROM 110°. Postoperatively, the WBL percentage was corrected to 61.87%. At the final follow-up, the WOMAC score was 36, Lysholm score 82, VAS score 3, and knee ROM 140°. Pre- and postoperative imaging findings and functional follow-up are presented in Figs. 5 and 6 . Discussion MOWHTO originates from the "osteotomy" technique dating back to the Hippocratic era, with its core principle being the creation of a medically induced fracture in the tibia and its subsequent fixation in an ideal position 12 . With advancements in complication management and preoperative correction planning techniques, osteotomy has gained increasing recognition among surgeons in clinical practice, establishing itself as a significant surgical approach alongside total knee arthroplasty (TKA) 13 . Research have demonstrated that for relatively young patients with high levels of physical activity and severe alignment deformities, MOWHTO yields better outcomes compared to arthroplasty 14 . Should postoperative recurrence of pain or failure of alignment correction occur, arthroplasty may subsequently be performed. For relatively young patients with medial compartment osteoarthritis, MOWHTO represents an effective therapeutic approach 15 – 16 . The principle of MOWHTO is the alleviaton of excessive load on the medial compartment caused by lower limb deformities, transferring this overload from the medial knee joint compartment to the lateral compartment. Its advantages include preserving the patient's original knee joint while potentially promoting effective osteochondral regeneration and facilitating functional recovery 17 . Research confirmed that MOWHTO promotes periparticular osteochondral regeneration by influencing cartilage regeneration-related proteins, such as upregulating the expression of extracellular regulated protein kinases 1/2 (p-ERK1/2) 18 . However, multiple studies indicated that the efficacy of MOWHTO correlates weakly with the degree of cartilage regeneration 19 . The primary cause of patient discomfort remains excessive loading on the medial compartment. Consequently, the key factor contributing to postoperative symptom improvement remains effective alignment correction. Selecting appropriate and precise postoperative correction criteria is crucial for achieving excellent long-term outcomes after MOWHTO. However, significant debate persists regarding the optimal correction level for superior postoperative patient outcomes 20 . Common postoperative WBL percentages for MOWHTO are generally categorized into two ranges: 50–60% and 60–70%. The 60–70% correction range was first proposed by Fujisawa, who suggested that correcting WBL to 62.5% (the Fujisawa point) postoperatively is more beneficial for patient recovery 21 . Subsequent studies have confirmed the Fujisawa point as a relatively safe correction target. Achieving a postoperative WBL correction within the 60–70% range yields favourable outcomes 10 , 11 . However, some studies suggested that while adjusting the postoperative WBL percentage to the 60–70% range may sufficiently reduce medial knee joint pressure, it may also carry a risk of damaging the lateral knee joint compartment. Adjusting the postoperative WBL percentage to the 55% range, corresponding to the highest point of the lateral tibial spine, is relatively safer 22 . Kim et al. proposed that using the highest point of the lateral tibial spine as the ideal postoperative WBL adjustment site offers both safety and efficacy 23 . This site is less affected by anatomical variation, with an average value range of 56.9 ± 2.5% of the WBL percentage. In summary, multiple studies suggested that correcting the postoperative WBL percentage to a percentage within the 50–70% range is effective, though the optimal degree of postoperative WBL correction remains highly debated. Building on this, some studies proposed that the optimal degree of postoperative WBL correction may correlate with the patient's degree of osteoarthritis. They proposed individualized osteotomy based on the severity of the patient's osteoarthritis, emphasising preoperative planning tailored to individual patient characteristics to achieve more precise and effective treatment 24 – 26 . Martay et al. measured knee joint stresses corresponding to different degrees of postoperative WBL correction 8 . They found that when the postoperative WBL was less than 50%, the medial knee stress displayed no significant change compared to preoperative levels, indicating limited therapeutic efficacy. When postoperative WBL exceeded 65%, the lateral compartment cartilage experienced greater stress, making it susceptible to concentrated stress damage and potentially developing lateral compartment pain. Consequently, a safer postoperative WBL range is 50–65%, providing theoretical support for High tibial osteotomy(HTO) in treating medial compartment KOA. Current studies propose individualized preoperative planning based on the patient's preoperative osteoarthritis severity. The degree of postoperative WBL correction correlates positively with osteoarthritis severity: patients with more advanced disease require greater correction. For patients with Kellgren-Lawrence grades 1 and 2, adjusting to 50–55% yields favourable outcomes, while patients with grades 3 and 4 achieve better outcomes with adjustments exceeding 55% 27,28 . However, clinical application of MOWHTO for medial compartment KOA often targets relatively younger patients with Kellgren-Lawrence grades 3 or 4 who aim to return to work. Patients with grades 1 or 2 may opt for conservative treatments such as physiotherapy, intra-articular injections, or oral medication, potentially avoiding surgery 29 , 30 . Based on clinical practice, this retrospective comparative study selected patients with Kellgren-Lawrence grade 3 or 4 osteoarthritis. Pre- and postoperative analyses were conducted to validate treatment efficacy and compare clinical outcomes across different degrees of postoperative WBL correction. The results of the present study indicated that MOWHTO significantly improves joint function scores and lower limb alignment in patients with KOA of Kellgren-Lawrence grade 3 and 4 (P < 0.001). Optimal knee function scores and the lowest pain scores were observed when the WBL correction degree ranged over 55–60%. Postoperative thrombosis and complication rates were low across the three groups, with no significant intergroup differences (P > 0.05). Additionally, this study found that the change in PTSA before and after surgery was less than 2°, with no significant difference between the two (P > 0.05). Previous studies have demonstrated that MOWHTO may induce postoperative PTSA alterations, potentially affecting patellofemoral joint function 31 . However, changes in PTSA less than 2°do not significantly impact joint function, indicating that this procedure possesses a certain degree of safety 31 . The present study concluded that MOWHTO is a safe and reliable treatment for grade 3 or 4 medial compartment KOA in patients under 65 years of ages. Optimal clinical outcomes are achieved when the WBL percentage is corrected to the 55–60% range. The present study restricted MOWHTO to patients under 65 years of age, positing that the procedure offers greater value for this demographic. The rationale stems from the fact that KOA patients in this age group often find themselves at a crossroads between conservative treatment and TKA. Conservative treatments yield limited efficacy, while TKA represents a knee replacement procedure. MOWHTO offers an effective intermediate treatment option between these two approaches 14 , 32 . Primeau et al., found in a prospective study that performing MOWHTO in younger patients significantly reduced the risk of subsequent knee arthroplasty. Among their cohort, 79% of patients did not undergo knee arthroplasty within 10 years 14 . The present study exclusively enrolled KOA patients with Kellgren-Lawrence grade 3 or 4 who responded poorly to conservative treatment. This selection was made because most symptomatic patients with mild-to-moderate KOA show limited willingness to undergo surgery. Palmer et al., in a systematic review, found that in current reports, surgical outcomes for Kellgren-Lawrence grade 1 or 2 patients showed no significant difference compared to conservative management 33 . However, current mainstream personalised osteotomy approaches predominantly rely on Kellgren-Lawrence grading. Feucht et al. proposed that patients with grades 1 and 2 are suitable for 50–55% postoperative WBL correction, as excessive varus correction is ineffective for this group. Conversely, patients with grade 3 are suitable for postoperative WBL correction exceeding 55% 24 . Hohloch et al. found that the optimal postoperative WBL correction for grade 3 patients is 55–60%, but with 60–65% correction yielding no further improvement. Currently, we are unaware of any reports regarding MOWHTO treatment for grade 4 KOA patients 28 . The present study included patients with grade 3 and 4 Kellgren-Lawrence KOA, revealing significant symptom improvement in all cases. A postoperative WBL correction of 55–60% proved most beneficial for patient recovery, providing practical evidence for the clinical application of MOWHTO in treating mid-to-late-stage KOA. Based on preoperative planning for individualized osteotomy, multiple studies suggested that a postoperative WBL correction of 50–55% is more prudent. Patients with Kellgren-Lawrence grade 3 are suitable for a postoperative WBL correction of 55–60%, but excessive varus correction is not considered to yield significant symptomatic improvement 24 , 27 – 28 . In the present study, patients achieving 55–60% postoperative WBL correction demonstrated the best outcomes, followed by those with 60–65% correction, while the poorest outcomes were observed in the 50–55% group. This discrepancy primarily stems from the exclusion of Kellgren-Lawrence grade 1 and 2 patients in this study, while grade 3 and 4 patients are not entirely suitable for 50–55% postoperative WBL correction. Kim et al. proposed using the highest point of the lateral intercondylar crest of the tibia as an assessment landmark for selecting the WBL, arguing that anatomical variations necessitate individualized WBL positioning based on surface landmarks 22 . The present study targeted the slope of the lateral intercondylar eminence as the surgical site, yielding varying degrees of postoperative WBL correction. Results indicated that correcting WBL to 55–60% postoperatively yielded optimal clinical outcomes, and the 55–60% WBL site coincided precisely with the vicinity of the highest point of the lateral intercondylar crest. Therefore, when using MOWHTO to treat moderate-to-severe KOA, the highest point of the lateral intercondylar crest may also be considered the ideal postoperative WBL correction site. Meanwhile, multiple studies suggested that patients with KOA accompanied by cruciate or collateral ligament injuries should not be subjected to excessive postoperative varus correction. However, there are currently no reports on the ideal postoperative WBL correction site for patients with mid-to-late-stage KOA and concomitant cruciate or collateral ligament injuries. The present study did not include such patients, necessitating further clinical investigation 24 , 27 – 28 . In summary, the optimal degree of postoperative WBL correction varies among individuals and requires personalised preoperative planning based on the severity of osteoarthritis and associated injuries. In terms of the surgical approach for individualized osteotomy, the present study employed traditional techniques, including target point localization and operative instruments. Recent studies have employed modern technology for personalized osteotomy, facilitating accurate intraoperative positioning and precise control of the WBL to achieve precise bone resection. Starting with preoperative measurements, Marti et al. utilised a "push" radiograph technique. Based on the patient's preoperative knee anteroposterior radiograph, they employed computer simulation technology to "push" the affected limb into a normal mechanical position, generating a virtual radiograph with an ideal force line and an intuitive view, representing the optimal force line correction. Chernchujit et al. employed three-dimensional (3D) computer-aided design to simulate the ideal correction process, thereby determining the optimal correction angle 27 , 34 . While these methods accurately determine the ideal position of individualized alignment lines, they do not enhance the precision of intraoperative osteotomy, leaving the potential for undercorrection or overcorrection. Consequently, improving the accuracy of intraoperative procedures is also a critical consideration for individualized osteotomy. Focusing on intraoperative techniques, multiple studies have demonstrated that customized instruments are emerging as a new approach to enhance the accuracy of intraoperative corrections. These technologies primarily include 3D-printed patient-specific instrumentation (PSI) and computer-assisted surgery (CAS). Cerciello et al., demonstrated through a meta-analysis that these techniques significantly reduce postoperative outliers, with PSI also effectively improves the accuracy of coronal plane correction 35 – 38 . Zaffagnini et al. found that PSI enhances the postoperative efficacy of MOWHTO and introduced a novel personalised 3D printing technique. This technique employs Miniaci's method for digital planning based on preoperative weight-bearing X-rays and Computed Tomography(CT) scans of the lower limb. Using planning software, it generates customized screw and drill hole lengths according to individual tibial surface geometry. Medical-grade titanium alloy is then used to print the required plates and screws, thereby enhancing the accuracy of intraoperative osteotomy and lower limb alignment control 35 , 39 . Compared to traditional PSI, this novel personalised 3D printing technology enables surgical procedures and instruments to better align with individual patient conditions through individualized simulation of tibial anatomy, significantly improving osteotomy accuracy. Additionally, Song et al. identified CAS's advantage in effectively controlling postoperative abnormal values, with experienced practitioners also ensuring the accuracy of CAS correction 40 . In summary, PSI and CAS, as cutting-edge technologies, can effectively enhance the accuracy of MOWHTO and hold promising prospects. Future prospective studies could utilise these technologies to transition from "observing postoperative alignment correction" to "setting target alignment", conducting prospective research to further determine the optimal postoperative WBL correction levels for patients with different characteristics. The limitations of this study are as follows: 1. The efficacy was observed only in patients with Kellgren-Lawrence grade 3 or 4 osteoarthritis postoperatively, without further stratification based on the severity of osteoarthritis. Future work will examine the impact of different osteoarthritis severity levels on the postoperative efficacy of MOWHTO under specific WBL conditions, based on the severity of osteoarthritis. 2. This retrospective study featured a relatively short follow-up period, lacking mid- to long-term outcomes. Future prospective cohort studies will precisely examine postoperative functional recovery and cartilage wear progression across different patient groups at multiple time points. 3. The study was confined to clinical indicators without examining biomechanical or cellular-molecular factors across groups, thus lacking deeper mechanistic investigation. Future work will establish 3D finite element models of the knee joint for different groups based on clinical findings, enabling more thorough investigation of how varying the WBL influences MOWHTO outcomes. Conclusion MOWHTO demonstrates excellent clinical efficacy in treating medial compartment KOA, serving as an effective therapeutic approach for moderate-to-severe KOA. The degree of WBL correction exhibits individual variability, with 55–60% correction being considered the optimal postoperative WBL correction point for moderate-to-severe MOWHTO. Abbreviations MOWHTO Medial open wedge high tibial osteotomy WBL Weight bearing line HKA Hip-knee-ankle MPTA Medial proximal tibial angle JLCA Joint line convergence angle PTSA Posterior tibial slope angle ROM Range of motion VAS Visual analogue scale WOMAC Western Ontario and McMaster Universities Osteoarthritis Index KOA Knee osteoarthritis MRI Magnetic resonance imaging K-wires Kirschner wires TKA Total knee arthroplasty p-ERK1/2 Protein kinases 1/2 HTO High tibial osteotomy 3D Three-dimensional PSI Patient-specific instrumentation CAS Computer-assisted surgery CT Computed Tomography Declarations Acknowledgements We are grateful to the Luoyang Orthopedic Hospital of Henan Province (Orthopedic Hospital of Henan Province) for allowing us to use these data retrospectively and providing support for statistical analysis. Author contributions: Yisan Wang and Guorui Cao Interpreted the data and prepared the manuscript. Xiao Wang, Peizhao Wang, Xiaotao Shi and Mingyang Zhang Collected the data. Honglue Tan Conceptualized and designed the study. Funding Obtain funds from the following sources: Henan Provincial Key Scientific and Technological Project (252102310082); Henan Provincial Key Scientific and Technological Project (242102310025); Henan Provincial Traditional Chinese Medicine Research Special Joint Construction Project (2025LHZX5003); Henan Provincial Overseas Returnees Research Priority Funding Project (2024-11); Henan Provincial Special Research Project on Traditional Chinese Medicine (2024ZY3067); Henan Provincial Postdoctoral Research Funding Programme (365154). Data availability The data and materials used and/or analyzed during the current study are not publicly available but available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was reviewed and approved by the Medical Ethics Committee of Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital) (Approval No.: 2025KYKT0031-02). All patients provided informed consent and voluntarily participated in this study, signing an "Informed Consent Form". We confirm that all methods were performed in accordance with the relevant guidelines and regulations. Consent for publication Not applicable. Competing interests The authors declare that there is no competing of interest. Author details 1 College of Orthopedics, Henan University of Chinese Medicine, Zhengzhou, Henan Province, People’s Republic of China. 2 Department of Knee surgery, Luoyang Orthopedic Hospital of Henan Province. Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People’s Republic of China. References Jang S, Lee K, Ju JH. Recent Updates of Diagnosis, Pathophysiology, and Treatment on Osteoarthritis of the Knee. Int J Mol Sci. 2021;22(5):2619. Hall M, van der Esch M, Hinman RS, et al. How does hip osteoarthritis differ from knee osteoarthritis? Osteoarthritis Cartilage. 2022;30(1):32–41. Sharma L. Osteoarthritis of the Knee. N Engl J Med. 2021;384(1):51–9. Palmer J, Getgood A, Lobenhoffer P. Medial opening wedge high tibial osteotomy for the treatment of medial unicompartmental knee osteoarthritis: A state-of-the-art review. J ISAKOS. 2024;9(1):39–52. Wang X, Shi L, Zhang R, Wang W, et al. Salvage of severe knee osteoarthritis: efficacy of tibial condylar valgus osteotomy versus open wedge high tibial osteotomy. J Orthop Surg Res. 2021;16(1):451. 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(3):585–608. Amis AA. Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):197–205. Martay JL, Palmer AJ, Bangerter NK, et al. A preliminary modeling investigation into the safe correction zone for high tibial osteotomy. Knee. 2018;25(2):286–95. Erdem A, Uçan V, Lebe G, et al. Impact of mechanical axis position and coronal plane alignment phenotypes on clinical outcomes in medial opening wedge high tibial osteotomy. Int Orthop. 2025;49(11):2607–13. Gohal C, Shanmugaraj A, Tate P, et al. Effectiveness of Valgus Offloading Knee Braces in the Treatment of Medial Compartment Knee Osteoarthritis: A Systematic Review. Sports Health. 2018 Nov/Dec;10(6):500–14. Moon HS, Choi CH, Yoo JH, et al. An Increase in Medial Joint Space Width After Medial Open-Wedge High Tibial Osteotomy Is Associated With an Increase in the Postoperative Weight-Bearing Line Ratio Rather Than With Cartilage Regeneration: Comparative Analysis of Patients Who Underwent Second-Look Arthroscopic Assessment. Arthroscopy. 2021;37(2):657–e6684. Pullen WM, Slone H, Abrams G. High Tibial Osteotomy in Knee Reconstruction and Joint Preservation. J Am Acad Orthop Surg. 2024;32(13):577–86. Zhang B, Qian H, Wu H, et al. Unicompartmental knee arthroplasty versus high tibial osteotomy for medial knee osteoarthritis: A systematic review and meta-analysis. J Orthop Surg (Hong Kong). 2023 Jan-Apr;31(1):10225536231162829. Primeau CA, Birmingham TB, Leitch KM, et al. Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors. CMAJ. 2021;193(5):E158–66. Cigercioglu N, Ozer H, Baltaci G. Comparison of Functional Outcomes of High Tibial Osteotomy and Unicompartmental Knee Arthroplasty in Patients with Medial Knee Osteoarthritis. J Knee Surg. 2025 Oct 14. Ahrend MD, Petzold D, Histing T, et al. High survival rates and patient satisfaction 12 years after medial open wedge HTO surgery: A prospective cohort study. Knee Surg Sports Traumatol Arthrosc. 2025;33(12):4344–52. Murray R, Winkler PW, Shaikh HS, et al. High Tibial Osteotomy for Varus Deformity of the Knee. J Am Acad Orthop Surg Glob Res Rev. 2021;5(7):e2100141. Wu J, Zhao B, Luo W, et al. Arthroscopy combined with high tibial osteotomy promotes cartilage regeneration in osteoarthritis. J Orthop Surg (Hong Kong). 2023 Jan-Apr;31(1):10225536231165357. Kim KI, Lee SH, Kim JH. The Presence or Absence of Cartilage Regeneration Following Medial Open-Wedge High Tibial Osteotomy Does Not Predict Long-Term Outcomes. Arthroscopy. 2025;41(12):5230–e52421. Dhillon J, Kraeutler MJ, Fasulo SM, et al. Isolated Osteotomy Versus Combined Osteotomy and Cartilage Repair for Osteoarthritis or Focal Chondral Defects of the Medial Compartment of the Knee Joint: A Systematic Review. Orthop J Sports Med. 2023;11(5):23259671231162030. Tseng TH, Wang HY, Tzeng SC, et al. Knee-ankle joint line angle: a significant contributor to high-degree knee joint line obliquity in medial opening wedge high tibial osteotomy. J Orthop Surg Res. 2022;17(1):79. Kim HJ, Park J, Shin JY, et al. More accurate correction can be obtained using a three-dimensional printed model in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2018;26(11):3452–8. Kim TW, Won JS. Anatomical Study of the Lateral Tibial Spine as a Landmark for Weight Bearing Line Assessment during High Tibial Osteotomy. Med (Kaunas). 2023;59(9):1571. Feucht MJ, Minzlaff P, Saier T, et al. Degree of axis correction in valgus high tibial osteotomy: proposal of an individualized approach. Int Orthop. 2014;38(11):2273–80. Han J, Xu W, Liu J, et al. Effect of different distraction gaps in open wedge high tibial osteotomy on the mechanical distribution around the knee joint: A finite element analysis and clinical validation. J Orthop Surg (Hong Kong). 2025 Sep-Dec;33(3):10225536251383123. Valente G, Grenno G, Benedetti MG, Zaffagnini S, et al. Altered motor function during daily activities in patients eligible for high tibial osteotomy is primarily driven by knee varus deformity. Bone Jt Open. 2025;6(4):454–62. Marti CB, Gautier E, Wachtl SW, et al. Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy. 2004;20(4):366–72. Hohloch L, Kim S, Mehl J, et al. Customized post-operative alignment improves clinical outcome following medial open-wedge osteotomy. Knee Surg Sports Traumatol Arthrosc. 2018;26(9):2766–73. Peng H, Ou A, Huang X, et al. Osteotomy Around the Knee: The Surgical Treatment of Osteoarthritis. Orthop Surg. 2021;13(5):1465–73. Carland A, Weiss-Laxer N, Martindale M, et al. Reasons for Not Enrolling in a Randomized Clinical Trial and Patient Preferences for Knee Osteoarthritis Treatment. J Patient Exp. 2025;12:23743735251383853. Ji S, Gao Y, Zhang J, et al. High tibial lateral closing wedge and opening wedge valgus osteotomy produce different effects on posterior tibial slope and patellar height. Front Surg. 2023;10:1219614. Rajgopal A, Dahiya V, Bhatnagar A, et al. Predictors of outcome following two-stage revision total knee arthroplasty. Arch Orthop Trauma Surg. 2024;144(12):5283–91. Palmer JS, Monk AP, Hopewell S, et al. Surgical interventions for symptomatic mild to moderate knee osteoarthritis. Cochrane Database Syst Rev. 2019;7(7):CD012128. Chernchujit B, Tharakulphan S, Prasetia R, et al. Preoperative planning of medial opening wedge high tibial osteotomy using 3D computer-aided design weight-bearing simulated guidance: Technique and preliminary result. J Orthop Surg (Hong Kong). 2019 Jan-Apr;27(1):2309499019831455. Zaffagnini S, Dal Fabbro G, Belvedere C, et al. Custom-Made Devices Represent a Promising Tool to Increase Correction Accuracy of High Tibial Osteotomy: A Systematic Review of the Literature and Presentation of Pilot Cases with a New 3D-Printed System. J Clin Med. 2022;11(19):5717. Cerciello S, Ollivier M, Corona K, et al. CAS and PSI increase coronal alignment accuracy and reduce outliers when compared to traditional technique of medial open wedge high tibial osteotomy: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2022;30(2):555–66. Victor J, Premanathan A. Virtual 3D planning and patient specific surgical guides for osteotomies around the knee: a feasibility and proof-of-concept study. Bone Joint J. 2013;95-B(11 Suppl A):153–8. Jones GG, Jaere M, Clarke S, et al. 3D printing and high tibial osteotomy. EFORT Open Rev. 2018;3(5):254–9. Elson DW, Petheram TG, Dawson MJ. High reliability in digital planning of medial opening wedge high tibial osteotomy, using Miniaci's method. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):2041–8. Song SJ, Bae DK, Park SH, et al. Surgical accuracy of coronal and sagittal alignment in conventional closed-wedge high tibial osteotomy after computer-assisted surgery experience. Knee Surg Relat Res. 2023;35(1):29. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 28 Jan, 2026 Editor assigned by journal 16 Jan, 2026 Submission checks completed at journal 16 Jan, 2026 First submitted to journal 16 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8621213","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582123327,"identity":"7f32e097-b7d9-4ebd-9937-1ab5907c80cd","order_by":0,"name":"Yisan Wang","email":"","orcid":"","institution":"Henan University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yisan","middleName":"","lastName":"Wang","suffix":""},{"id":582123328,"identity":"db660b01-ad11-4893-b688-e337615266f9","order_by":1,"name":"Guorui Cao","email":"","orcid":"","institution":"Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Guorui","middleName":"","lastName":"Cao","suffix":""},{"id":582123329,"identity":"ce9fd6f5-078d-4efc-b513-7a038a39e414","order_by":2,"name":"Xiao Wang","email":"","orcid":"","institution":"Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"Wang","suffix":""},{"id":582123330,"identity":"9c5e8c73-5647-4096-9aea-d64d18a0b556","order_by":3,"name":"Peizhao Wang","email":"","orcid":"","institution":"Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Peizhao","middleName":"","lastName":"Wang","suffix":""},{"id":582123331,"identity":"fcef62e3-5fe5-4301-b1e7-f8e1b560f671","order_by":4,"name":"Xiaotao Shi","email":"","orcid":"","institution":"Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Xiaotao","middleName":"","lastName":"Shi","suffix":""},{"id":582123332,"identity":"d46d639f-a4cd-4116-83f2-01ced6b5ba0e","order_by":5,"name":"Mingyang Zhang","email":"","orcid":"","institution":"Henan University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mingyang","middleName":"","lastName":"Zhang","suffix":""},{"id":582123333,"identity":"00b953e8-4f90-42c1-b5ea-4e9e12bf7d06","order_by":6,"name":"Honglüe Tan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYBACAwbmBgaGAiCLvbHx4QfitDA2gEgGBp7DzcYSpGmRSG8T4CFGi7l0Y+MHBgObxH7Jh20MEgx2croNBLRYzjnYLMFgkJY4c3Zi24MChmRjswOEHHYjsQ1IHjY2uJ3YbiDBcCBxG9Fa7G8ebJPgIUWLnIEEI/FamiUSDNLkJM4kAgPZgCi/JB/88KHChoe//fjDhx8q7OQIagGDBIQJxCgfBaNgFIyCUUAQAACPEz+aynZrBwAAAABJRU5ErkJggg==","orcid":"","institution":"Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital)","correspondingAuthor":true,"prefix":"","firstName":"Honglüe","middleName":"","lastName":"Tan","suffix":""}],"badges":[],"createdAt":"2026-01-16 17:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8621213/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8621213/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101498528,"identity":"a96374b3-f71b-492b-96c5-fc80851f7bc5","added_by":"auto","created_at":"2026-01-30 13:06:51","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87416,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic of the WBL measurement method\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8621213/v1/5b3cacd25433ecf40045eaf6.jpeg"},{"id":101498529,"identity":"be9b371f-7e7b-4087-94a0-1cfe1e9ab4e0","added_by":"auto","created_at":"2026-01-30 13:06:51","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":309270,"visible":true,"origin":"","legend":"\u003cp\u003eFull-length radiographs of both lower limbs before and after surgery. Comparison reveals preoperative medial joint space narrowing and pronounced varus alignment. Postoperative images demonstrate well-corrected alignment, properly positioned plate fixation, and improved medial joint space.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8621213/v1/3fead81e54e366cf2c5ab5bb.jpeg"},{"id":101498533,"identity":"91367f91-9217-4dfa-9a0a-4be9f45bee78","added_by":"auto","created_at":"2026-01-30 13:06:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1179539,"visible":true,"origin":"","legend":"\u003cp\u003eAt the final follow-up visit, the patient demonstrated good knee function. There was no significant pain or functional impairment during squatting or standing. Simple activities such as stair climbing and light jogging were possible.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8621213/v1/23750436be4ca5cd7f6c5d4d.png"},{"id":101752353,"identity":"b21b2a6c-0543-4f37-aedb-c6d9b5b0fe2b","added_by":"auto","created_at":"2026-02-03 10:26:59","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":302593,"visible":true,"origin":"","legend":"\u003cp\u003eFull-length radiographs of both lower limbs before and after surgery. Comparison reveals preoperative medial joint space narrowing and pronounced varus alignment. Postoperatively, alignment is well corrected, the plate is properly positioned, and the medial joint space has improved.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8621213/v1/c1111734f4f5f93e58b00f7a.jpeg"},{"id":101498534,"identity":"57e2c0ac-4128-4c88-9d8f-6b9789febe98","added_by":"auto","created_at":"2026-01-30 13:06:51","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":355277,"visible":true,"origin":"","legend":"\u003cp\u003eFull-length radiographs of both lower limbs before and after surgery. Comparison reveals preoperative medial joint space narrowing and pronounced varus alignment. Postoperatively, alignment is well corrected, the plate is properly positioned, and the medial joint space has improved.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8621213/v1/0b1382c52b07183c6a5a6464.jpeg"},{"id":101498530,"identity":"2b184065-d076-4422-8545-b2324bec7c9a","added_by":"auto","created_at":"2026-01-30 13:06:51","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":767467,"visible":true,"origin":"","legend":"\u003cp\u003eAt the final follow-up visit, the patient demonstrated good knee function with no significant pain or functional impairment during squatting or standing. Simple activities such as stair climbing and light jogging were achievable.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8621213/v1/efb8dca43cbe906ef44f4afb.png"},{"id":101756422,"identity":"7c031f61-ced7-4fdd-8518-a118f7c600e0","added_by":"auto","created_at":"2026-02-03 10:57:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4519808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8621213/v1/c5dc10a2-d6db-46de-baa6-aa0e4021d735.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of the Efficacy of High Tibial Osteotomy in Treating Knee Osteoarthritis at Different Levels of Weight Bearing Line Correction","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKnee osteoarthritis (KOA) is a common degenerative disease of the knee joint, predominantly affecting middle-aged and elderly individuals. Its primary causes\u0026nbsp;originate\u0026nbsp;from frequent use of the knee joint, chronic wear and tear, and uneven pressure distribution. Its key risk factors include genetics, age, osteoporosis, and obesity\u003csup\u003e1\u003c/sup\u003e. The\u0026nbsp;main\u0026nbsp;pathogenesis\u0026nbsp;of KOA\u0026nbsp;involves\u0026nbsp;the\u0026nbsp;activation of inflammatory pathways due to factors such as the loss of chondrocytes\u003csup\u003e2\u003c/sup\u003e. The primary symptoms of KOA include pain, stiffness, and impaired joint function. Without timely intervention, it can significantly impact patients\u0026apos; quality of life, leading to muscle atrophy, reduced physical activity, poor sleep quality, and\u0026nbsp;even\u0026nbsp;adverse outcomes such as disability and depression \u003csup\u003e3\u003c/sup\u003e. Consequently, timely treatment of KOA to relieve pain and improve function is crucial for alleviating\u0026nbsp;patient suffering.\u003c/p\u003e\n\u003cp\u003eTreatment options for KOA primarily include oral medication, intra-articular injections, and surgical interventions. Surgical approaches mainly involve total or unilateral knee arthroplasty and osteotomy procedures \u003csup\u003e1\u003c/sup\u003e. Among these, osteotomy can effectively corrects lower limb alignment to substantially improve varus/valgus deformities. This technique can preserves the patient\u0026apos;s natural knee structure while achieving symptomatic relief. For relatively younger patients requiring continued physical labour, osteotomy represents an effective surgical technique that maximizes the probability of achieving the desired therapeutic outcomes \u003csup\u003e4\u003c/sup\u003e. Medial knee osteoarthritis is the most common type of KOA. For patients with medial compartment osteoarthritis who are unresponsive to conservative management, medial open wedge high tibial osteotomy (MOWHTO) has\u0026nbsp;become a well-established surgical technique with satisfactory clinical outcomes\u0026nbsp;\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe primary objective of MOWHTO is to adjust the weight-bearing line (WBL). The degree of WBL correction (postoperative WBL percentage) is defined as the ratio of the line length connecting the intersection point of the weight-bearing line and the tibial plateau to the medial point of the tibial plateau, divided by the entire width of the tibial plateau. However, there remains no definitive consensus on the optimal percentage of postoperative WBL adjustment for maximizing functional recovery in patients with KOA. In 1979, Fujisawa et al. concluded through clinical research that correcting the postoperative WBL percentage to 62.5% most effectively promotes functional recovery \u003csup\u003e6\u003c/sup\u003e. For decades, this degree of correction has been consistently followed by orthopedic surgeons and is widely recognized as a relatively safe and effective postoperative correction target. In recent years, with the increasing volume of MOWHTO procedures, researchers have proposed different\u0026nbsp;opinions\u0026nbsp;through various perspectives. Amis et al. contended that the Fujisawa point represents an empirical standard derived from tradition, lacking rational validation through evidence-based science \u003csup\u003e7\u003c/sup\u003e. Martay et al., analysing from a biomechanical perspective, suggested that the safe range for the postoperative WBL percentage correction should lie between 50 and 65% \u003csup\u003e8\u003c/sup\u003e.\u0026nbsp;Erdem et al. found through clinical studies that optimal clinical outcomes were achieved when patients were corrected to a postoperative WBL\u0026nbsp;percentage\u0026nbsp;range of 50\u0026ndash;60% \u003csup\u003e9\u003c/sup\u003e. However, other studies have\u0026nbsp;demonstrated that adjusting\u0026nbsp;the\u0026nbsp;postoperative WBL\u0026nbsp;percentage\u0026nbsp;to the 60\u0026ndash;70% range yields\u0026nbsp;the\u0026nbsp;optimal clinical efficacy \u003csup\u003e10\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e11\u003c/sup\u003e. Therefore, the optimal degree of WBL correction for MOWHTO remains controversial, with no consensus reached. Identifying the optimal WBL correction level for MOWHTO holds significant clinical implications. This retrospective study aims to compare the clinical efficacy of MOWHTO treatment for medial knee osteoarthritis across different degrees of WBL correction, thereby providing clinicians and patients with more optimized and precise treatment options.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eInclusion Criteria: 1. Patients with moderate-to-severe KOA (with knee varus), primarily involving medial knee osteoarthritis with pain, who have failed conservative treatment for over 6 months, and exhibit Kellgren-Lawrence grade 3 or 4 on X-ray. 2. Weight-bearing X-rays showing medial joint space narrowing, the angle of knee varus\u0026thinsp;\u0026gt;\u0026thinsp;5\u0026deg;, an essentially normal lateral joint space, and generally intact knee joint structure; Magnetic resonance imaging(MRI) indicating intact knee ligaments, stable knee joint, and an absence of dislocation changes; 3. Patients with knee flexion-extension range of motion\u0026thinsp;\u0026gt;\u0026thinsp;100\u0026deg;, varus angle\u0026thinsp;\u0026lt;\u0026thinsp;30\u0026deg;, and flexion contracture\u0026thinsp;\u0026lt;\u0026thinsp;10\u0026deg;; 4. Patients aged\u0026thinsp;\u0026lt;\u0026thinsp;65 years.\u003c/p\u003e \u003cp\u003eExclusion criteria: 1. Patients with anterior cruciate ligament or collateral ligament injuries; 2. Patients with moderate-to-severe osteoarthritis in the patellofemoral or lateral compartments; 3. Patients with severe systemic medical conditions deemed intolerant to surgery following assessment; 4. Patients with active infection at the surgical site or systemic infection; 5. Patients with psychiatric disorders or those who are pregnant; 6. Patients with severe osteoporosis; 7. Patients with bone diseases caused by other conditions such as gout, rheumatoid arthritis, ankylosing spondylitis, or tumours; 8. Patients with peripheral pathology around the knee joint; 9. Patients who had undergone previous knee surgery or recent intra-articular injections.\u003c/p\u003e \u003cp\u003e This study was reviewed and approved by the Medical Ethics Committee of Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital) (Approval No.: 2025KYKT0031-02). All patients provided informed consent and voluntarily participated in this study, signing an \"Informed Consent Form\".\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Information\u003c/h2\u003e \u003cp\u003eThis retrospective study screened 210 patients who underwent MOWHTO at our hospital's Knee Surgery Department between April 2016 and November 2024. Thirteen patients were excluded based on exclusion criteria. A further 11 patients were excluded due to incomplete imaging data or contact information preventing follow-up completion. During follow-up, six patients withdrew for personal reasons. Ultimately, 180 eligible patients were included. Postoperative full-length lower limb radiographs were obtained to calculate the degree of WBL correction using the following method: First, a line connecting the center of the femoral head to the center of the ankle joint was drawn, and the intersection of this line with the tibial plateau was identified. The distance from this intersection to the medial edge of the tibial plateau was designated as value a, while the total width of the tibial plateau (measured along the line connecting the medial and lateral edges) was designated as value b. The degree of correction was calculated as: Correction degree\u0026thinsp;=\u0026thinsp;a / b \u0026times; 100% as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients were grouped based on the range of postoperative WBL correction: those with 50\u0026ndash;55% correction constituted Group A, 55\u0026ndash;60% Group B, and 60\u0026ndash;65% Group C. Group A comprised 70 patients, Group B 51, and Group C 59.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTreatment Approach\u003c/h3\u003e\n\u003cp\u003ePreoperative interventions: Upon admission, comprehensive examinations were conducted, including weight-bearing anteroposterior and lateral X-rays of both knees, full-length weight-bearing radiographs of both lower limbs, knee MRI, blood and urine routine tests, blood biochemistry, coagulation panel, liver and kidney function tests, inflammatory markers, electrocardiogram, chest X-ray, cardiac echocardiography, and bone density assessment. These tests confirmed surgical eligibility, ensured absence of significant underlying conditions, and excluded patients with severe osteoporosis.\u003c/p\u003e \u003cp\u003eSurgical Approach: The patient was positioned supine. Following successful anaesthesia, arthroscopy was performed first. Two incisions of approximately 0.5 cm were made on the anteromedial and anterolateral aspects of the affected knee. The anterior-lateral approach was employed to insert the arthroscope to examine the meniscus and cartilage within the knee joint. Proliferative synovial tissue and loose cartilage fragments within the joint cavity were cleared. If meniscal damage was present, perform arthroscopic suturing or partial meniscectomy based on the location and severity of the damage. After the treament, stability was assessed using a probe. Hemostasis, irrigation, and closure of the incision were performed. Following arthroscopic exploration and initial management, a 7 cm oblique incision was made 2 cm medial to the tibial tubercle. Layers were dissected along anatomical planes, separating skin and subcutaneous tissue to identify the medial collateral ligament and pes anserinus. The deep insertion of the medial collateral ligament was dissected and transected. A Hoffman retractor was employed to protect the patellar tendon and neurovascular bundle. Two parallel Kirschner wires (K-wires) were inserted parallel to the superior border of the pes anserinus, directed toward the ipsilateral tibiofibular syndesmosis. The depth of the wires within the bone was measured. C-arm fluoroscopy was applied to monitor K-wire positioning. After adjusting the K-wires to the planned depth and angle, oblique and transverse osteotomies were performed using a reciprocating saw, preserving approximately 1 cm of the lateral hinge. Stacked bone saws were inserted sequentially to enlarge and refine the osteotomy plane. Position spreaders were used to maintain the angulation, inducing slight leg varus. The saws were removed and the angulation was temporarily stabilised with crossed K-wires. The alignment was re-assessed by intraoperative fluoroscopy, ensuring the force line passed through the center of the hip joint (typically the center of the femoral head) and the center of the ankle joint (normally the midpoint of the talus width). The alignment was adjusted under C-arm fluoroscopy guidance to traverse the slope of the lateral intercondylar crest. Once proper alignment correction was confirmed, The spread-open bone was secured with plates and screws. When the distraction gap exceeded 15 mm, artificial bone or autologous iliac bone was implanted. After reconfirming secure fixation with C-arm fluoroscopy, the incision was irrigated, a negative pressure drainage tube was placed in the wound, which was subsequently closed in layers, and the wound was closed in layers. The incision site was covered with gauze and the affected area bandaged with an elastic bandage.\u003c/p\u003e\n\u003ch3\u003ePostoperative Management\u003c/h3\u003e\n\u003cp\u003eStandard protocols for infection prevention, oedema reduction, analgesia, and anticoagulation were implemented postoperatively. Bed rest with elevation of the affected limb was prescribed to reduce swelling. The drainage tube was removed once the daily drainage volume fell below 50 ml per 24 hours. On the first postoperative day, the patient was instructed to perform ankle pump exercises and quadriceps muscle strengthening exercises in bed. On the second day, the patient was advised to bear partial weight with crutch support, continuing ankle pump exercises, knee flexion/extension movements, and quadriceps strengthening exercises. Sutures were removed at 2 weeks postoperatively. Full weight-bearing was permitted at 4\u0026ndash;6 weeks, with normal activities resumed after 3 months.\u003c/p\u003e\n\u003ch3\u003eObservation Indicators\u003c/h3\u003e\n\u003cp\u003ePreoperative and final follow-up bilateral full-leg length measurements and weight-bearing anteroposterior/lateral knee radiographs were obtained. The hip-knee-ankle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), and posterior tibial slope angle (PTSA) were determined. Postoperative joint function and recovery were assessed using the range of motion (ROM), visual analogue scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and Lysholm knee score. Perioperative data (including operative time, postoperative thrombotic events, wound complications, etc.) were obtained to evaluate surgical safety.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analysed using SPSS 27.0 software (IBM Corporation, USA). Quantitative data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u0026oline;x\u0026thinsp;\u0026plusmn;\u0026thinsp;s), while categorical data were presented as counts/ratios. For intergroup comparisons, data normality and homogeneity of variance were assessed. If data met normality and homogeneity criteria, one-way analysis of variance was employed. Otherwise, the Kruskal-Wallis test was used. For pre- and postoperative comparisons, independent samples t-tests were applied to data meeting normality and homogeneity of variance criteria. Rank-sum tests (Kruskal-Wallis tests) were employed for non-normally distributed or heteroscedastic data. Categorical data comparisons utilised chi-square or Fisher's exact probability tests. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated statistically significant differences. The statistical methodology was reviewed by our hospital's statistical experts.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Characteristics\u003c/h2\u003e \u003cp\u003eThere were no statistically significant differences in the mean follow-up duration among the three patient groups A to C (39.95\u0026thinsp;\u0026plusmn;\u0026thinsp;6.49 months, 39.53\u0026thinsp;\u0026plusmn;\u0026thinsp;6.69 months, 39.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.64 months, respectively; P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). There were no significant differences in age, sex, height, weight, body mass index, or Kellgren-Lawrence classification among the three groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral Characteristics of Patients in the Three Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.71\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.37\u0026thinsp;\u0026plusmn;\u0026thinsp;4.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.606\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male/Total, n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46/70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23/51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26/59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.929\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165.94\u0026thinsp;\u0026plusmn;\u0026thinsp;6.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165.26\u0026thinsp;\u0026plusmn;\u0026thinsp;7.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e165.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.891\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.69\u0026thinsp;\u0026plusmn;\u0026thinsp;10.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.85\u0026thinsp;\u0026plusmn;\u0026thinsp;9.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.69\u0026thinsp;\u0026plusmn;\u0026thinsp;9.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.838\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ebody mass index (BMI,Kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.56\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.21\u0026thinsp;\u0026plusmn;\u0026thinsp;2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative Time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.57\u0026thinsp;\u0026plusmn;\u0026thinsp;21.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.68\u0026thinsp;\u0026plusmn;\u0026thinsp;21.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80.42\u0026thinsp;\u0026plusmn;\u0026thinsp;20.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK-L Grade (Grade 3/Total, n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50/70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32/51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40/59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up Duration (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.95\u0026thinsp;\u0026plusmn;\u0026thinsp;6.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.53\u0026thinsp;\u0026plusmn;\u0026thinsp;6.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.898\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePreoperative Indicators\u003c/h3\u003e\n\u003cp\u003eThere were no statistically significant differences in relevant angles or functional scores among the three groups of patients prior to surgery (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Preoperative Indicators Among the Three Groups of Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHKA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e171.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e172.97\u0026thinsp;\u0026plusmn;\u0026thinsp;3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e173.92\u0026thinsp;\u0026plusmn;\u0026thinsp;5.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPTA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e83.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e84.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e85.59\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.357\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJLCA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.36\u0026thinsp;\u0026plusmn;\u0026thinsp;4.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.74\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e7.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e156.64\u0026thinsp;\u0026plusmn;\u0026thinsp;6.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e160.13\u0026thinsp;\u0026plusmn;\u0026thinsp;6.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e158.95\u0026thinsp;\u0026plusmn;\u0026thinsp;8.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Pain Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e31.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.717\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Stiffness Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e13.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e14.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Activity Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e111.86\u0026thinsp;\u0026plusmn;\u0026thinsp;6.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e114.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e113.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.469\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLysholm Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e20.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual Analogue Scale (VAS) (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e7.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.739\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e107.05\u0026thinsp;\u0026plusmn;\u0026thinsp;5.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e109.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e104.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Pre- and Postoperative Indicators\u003c/h2\u003e \u003cp\u003eThe postoperative HKA (180.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61 vs 172.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18) and MPTA (88.86\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80 vs 84.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52 ) increased significantly compared to preoperative levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the JLCA (3.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77 vs 3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59) decreased significantly (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The WOMAC scores (62.12\u0026thinsp;\u0026plusmn;\u0026thinsp;28.92 vs 158.51\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42) and related scores, the VAS scores (1.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26 vs 7.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85), were significantly reduced (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), the Lysholm scores (76.39\u0026thinsp;\u0026plusmn;\u0026thinsp;14.09 vs 20.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93) and ROM (128.93\u0026thinsp;\u0026plusmn;\u0026thinsp;13.91 vs 106.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.86) were significantly increased (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the PTSA showed no significant change from before to after surgery (8.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.97 vs 8.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93, P\u0026thinsp;=\u0026thinsp;0.645). Comparisons of imaging metrics and functional scores at baseline and final postoperative follow-up for all patients are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Preoperative and Postoperative Metrics for All Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative(n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative(n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHKA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e172.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e180.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPTA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e84.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e88.86\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJLCA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e158.51\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e62.12\u0026thinsp;\u0026plusmn;\u0026thinsp;28.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Pain Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e31.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.92\u0026thinsp;\u0026plusmn;\u0026thinsp;5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Stiffness Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Activity Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e113.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.39\u0026thinsp;\u0026plusmn;\u0026thinsp;21.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLysholm Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e76.39\u0026thinsp;\u0026plusmn;\u0026thinsp;14.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual Analogue Scale (VAS) (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e106.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e128.93\u0026thinsp;\u0026plusmn;\u0026thinsp;13.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Comparison Among the Three Patient Groups\u003c/h2\u003e \u003cp\u003eThe postoperative HKA and MPTA scores in the three groups displayed a gradual increase with greater correction (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, P\u0026thinsp;=\u0026thinsp;0.008), while no significant differences were observed for the JLCA or PTSA (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The postoperative WOMAC scores among the three groups A\u0026ndash;C (69.05\u0026thinsp;\u0026plusmn;\u0026thinsp;23.19, 50.93\u0026thinsp;\u0026plusmn;\u0026thinsp;29.06, 62.53\u0026thinsp;\u0026plusmn;\u0026thinsp;31.12, respectively, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), WOMAC pain scores (13.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.91, 10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39, 11.66\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15, respectively, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), WOMAC stiffness score (6.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.43, 4.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76, 5.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25, respectively, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), WOMAC activity score (48.64\u0026thinsp;\u0026plusmn;\u0026thinsp;16.75, 36.00\u0026thinsp;\u0026plusmn;\u0026thinsp;21.59, 45.24\u0026thinsp;\u0026plusmn;\u0026thinsp;23.35, respectively, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and VAS score (2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35, 1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94, 1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22, P\u0026thinsp;=\u0026thinsp;0.010) were lowest in Group B and highest in Group A.\u003c/p\u003e \u003cp\u003e Additionally, the Lysholm scores (69.23\u0026thinsp;\u0026plusmn;\u0026thinsp;16.86, 82.67\u0026thinsp;\u0026plusmn;\u0026thinsp;7.09, 78.05\u0026thinsp;\u0026plusmn;\u0026thinsp;12.95, respectively, P\u0026thinsp;=\u0026thinsp;0.004), ROM (123.18\u0026thinsp;\u0026plusmn;\u0026thinsp;14.84, 134.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.76, 130.00\u0026thinsp;\u0026plusmn;\u0026thinsp;14.09, respectively, P\u0026thinsp;=\u0026thinsp;0.013) were optimal in Group B, followed by Group C, with Group A displaying the poorest outcomes, demonstrating statistically significant differences. Detailed comparisons of outcome measures across the three groups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Outcome Measures Among the Three Groups (P values for pairwise comparisons between Group A and Group B, Group A and Group C, and Group B and Group C are denoted as P1, P2, and P3, respectively)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroupB(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHKA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e178.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e180.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e183.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPTA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e86.96\u0026thinsp;\u0026plusmn;\u0026thinsp;6.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.17\u0026thinsp;\u0026plusmn;\u0026thinsp;5.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e90.35\u0026thinsp;\u0026plusmn;\u0026thinsp;7.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJLCA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.99\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e8.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e69.05\u0026thinsp;\u0026plusmn;\u0026thinsp;23.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e50.93\u0026thinsp;\u0026plusmn;\u0026thinsp;29.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e62.53\u0026thinsp;\u0026plusmn;\u0026thinsp;31.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Pain Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e13.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e11.66\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Stiffness Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.439\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWOMAC Activity Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e48.64\u0026thinsp;\u0026plusmn;\u0026thinsp;16.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e36.00\u0026thinsp;\u0026plusmn;\u0026thinsp;21.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e45.24\u0026thinsp;\u0026plusmn;\u0026thinsp;23.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLysholm Score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e69.23\u0026thinsp;\u0026plusmn;\u0026thinsp;16.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e82.67\u0026thinsp;\u0026plusmn;\u0026thinsp;7.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e78.05\u0026thinsp;\u0026plusmn;\u0026thinsp;12.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual Analogue Scale (VAS) (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e123.18\u0026thinsp;\u0026plusmn;\u0026thinsp;14.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e134.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e130.00\u0026thinsp;\u0026plusmn;\u0026thinsp;14.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSafety Assessment Results\u003c/h2\u003e \u003cp\u003eNo statistically significant differences were observed in the incidence of thrombotic or wound complications among the three groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Safety Assessment Indicators for the Three Patient Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of postoperative wound complications (incidence rate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(4.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(5.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3(5.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of postoperative thrombosis cases (incidence rate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(4.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1(1.96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2(3.39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.490\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTypical Cases\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCase 1\u003c/strong\u003e \u003cp\u003e(Group A): A 61-year-old female patient with medial compartment osteoarthritis of the left knee. At admission, the patient\u0026rsquo;s knee WOMAC score was 150, Lysholm score 28, VAS score 8, and knee ROM 115\u0026deg;. The patient underwent arthroscopic meniscectomy and MOWHTO. Postoperatively, the WBL percentage was corrected to 51.04%. At the final follow-up, the WOMAC score was 66, Lysholm score 74, VAS score 3, and knee ROM 140\u0026deg;. Pre- and postoperative imaging findings and functional status at the final follow-up are presented in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 2\u003c/strong\u003e \u003cp\u003e(Group B) involved a 60-year-old female patient with medial compartment osteoarthritis of the right knee. At admission, the knee WOMAC score was 164, Lysholm score 14, VAS score 6, and knee ROM 120\u0026deg;. Postoperatively, the WBL percentage was corrected to 56.35%. At the final follow-up, the WOMAC score was 48, Lysholm score was 85, VAS score 2, and knee ROM 130\u0026deg;. Pre- and postoperative imaging findings are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 3\u003c/strong\u003e \u003cp\u003e(Group C): A 56-year-old male patient with medial compartment osteoarthritis of the right knee. At admission, the knee WOMAC score was 160, Lysholm score 28, VAS score 7, and knee ROM 110\u0026deg;. Postoperatively, the WBL percentage was corrected to 61.87%. At the final follow-up, the WOMAC score was 36, Lysholm score 82, VAS score 3, and knee ROM 140\u0026deg;. Pre- and postoperative imaging findings and functional follow-up are presented in Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMOWHTO originates from the \"osteotomy\" technique dating back to the Hippocratic era, with its core principle being the creation of a medically induced fracture in the tibia and its subsequent fixation in an ideal position \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. With advancements in complication management and preoperative correction planning techniques, osteotomy has gained increasing recognition among surgeons in clinical practice, establishing itself as a significant surgical approach alongside total knee arthroplasty (TKA) \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Research have demonstrated that for relatively young patients with high levels of physical activity and severe alignment deformities, MOWHTO yields better outcomes compared to arthroplasty\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Should postoperative recurrence of pain or failure of alignment correction occur, arthroplasty may subsequently be performed. For relatively young patients with medial compartment osteoarthritis, MOWHTO represents an effective therapeutic approach \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe principle of MOWHTO is the alleviaton of excessive load on the medial compartment caused by lower limb deformities, transferring this overload from the medial knee joint compartment to the lateral compartment. Its advantages include preserving the patient's original knee joint while potentially promoting effective osteochondral regeneration and facilitating functional recovery \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Research confirmed that MOWHTO promotes periparticular osteochondral regeneration by influencing cartilage regeneration-related proteins, such as upregulating the expression of extracellular regulated protein kinases 1/2 (p-ERK1/2) \u003csup\u003e18\u003c/sup\u003e. However, multiple studies indicated that the efficacy of MOWHTO correlates weakly with the degree of cartilage regeneration \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. The primary cause of patient discomfort remains excessive loading on the medial compartment. Consequently, the key factor contributing to postoperative symptom improvement remains effective alignment correction. Selecting appropriate and precise postoperative correction criteria is crucial for achieving excellent long-term outcomes after MOWHTO. However, significant debate persists regarding the optimal correction level for superior postoperative patient outcomes \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCommon postoperative WBL percentages for MOWHTO are generally categorized into two ranges: 50\u0026ndash;60% and 60\u0026ndash;70%. The 60\u0026ndash;70% correction range was first proposed by Fujisawa, who suggested that correcting WBL to 62.5% (the Fujisawa point) postoperatively is more beneficial for patient recovery \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Subsequent studies have confirmed the Fujisawa point as a relatively safe correction target. Achieving a postoperative WBL correction within the 60\u0026ndash;70% range yields favourable outcomes \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, some studies suggested that while adjusting the postoperative WBL percentage to the 60\u0026ndash;70% range may sufficiently reduce medial knee joint pressure, it may also carry a risk of damaging the lateral knee joint compartment. Adjusting the postoperative WBL percentage to the 55% range, corresponding to the highest point of the lateral tibial spine, is relatively safer \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Kim et al. proposed that using the highest point of the lateral tibial spine as the ideal postoperative WBL adjustment site offers both safety and efficacy \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. This site is less affected by anatomical variation, with an average value range of 56.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5% of the WBL percentage. In summary, multiple studies suggested that correcting the postoperative WBL percentage to a percentage within the 50\u0026ndash;70% range is effective, though the optimal degree of postoperative WBL correction remains highly debated. Building on this, some studies proposed that the optimal degree of postoperative WBL correction may correlate with the patient's degree of osteoarthritis. They proposed individualized osteotomy based on the severity of the patient's osteoarthritis, emphasising preoperative planning tailored to individual patient characteristics to achieve more precise and effective treatment \u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMartay et al. measured knee joint stresses corresponding to different degrees of postoperative WBL correction \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. They found that when the postoperative WBL was less than 50%, the medial knee stress displayed no significant change compared to preoperative levels, indicating limited therapeutic efficacy. When postoperative WBL exceeded 65%, the lateral compartment cartilage experienced greater stress, making it susceptible to concentrated stress damage and potentially developing lateral compartment pain. Consequently, a safer postoperative WBL range is 50\u0026ndash;65%, providing theoretical support for High tibial osteotomy(HTO) in treating medial compartment KOA. Current studies propose individualized preoperative planning based on the patient's preoperative osteoarthritis severity. The degree of postoperative WBL correction correlates positively with osteoarthritis severity: patients with more advanced disease require greater correction. For patients with Kellgren-Lawrence grades 1 and 2, adjusting to 50\u0026ndash;55% yields favourable outcomes, while patients with grades 3 and 4 achieve better outcomes with adjustments exceeding 55% \u003csup\u003e27,28\u003c/sup\u003e. However, clinical application of MOWHTO for medial compartment KOA often targets relatively younger patients with Kellgren-Lawrence grades 3 or 4 who aim to return to work. Patients with grades 1 or 2 may opt for conservative treatments such as physiotherapy, intra-articular injections, or oral medication, potentially avoiding surgery \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Based on clinical practice, this retrospective comparative study selected patients with Kellgren-Lawrence grade 3 or 4 osteoarthritis. Pre- and postoperative analyses were conducted to validate treatment efficacy and compare clinical outcomes across different degrees of postoperative WBL correction.\u003c/p\u003e \u003cp\u003eThe results of the present study indicated that MOWHTO significantly improves joint function scores and lower limb alignment in patients with KOA of Kellgren-Lawrence grade 3 and 4 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Optimal knee function scores and the lowest pain scores were observed when the WBL correction degree ranged over 55\u0026ndash;60%. Postoperative thrombosis and complication rates were low across the three groups, with no significant intergroup differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Additionally, this study found that the change in PTSA before and after surgery was less than 2\u0026deg;, with no significant difference between the two (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Previous studies have demonstrated that MOWHTO may induce postoperative PTSA alterations, potentially affecting patellofemoral joint function \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. However, changes in PTSA less than 2\u0026deg;do not significantly impact joint function, indicating that this procedure possesses a certain degree of safety \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. The present study concluded that MOWHTO is a safe and reliable treatment for grade 3 or 4 medial compartment KOA in patients under 65 years of ages. Optimal clinical outcomes are achieved when the WBL percentage is corrected to the 55\u0026ndash;60% range.\u003c/p\u003e \u003cp\u003eThe present study restricted MOWHTO to patients under 65 years of age, positing that the procedure offers greater value for this demographic. The rationale stems from the fact that KOA patients in this age group often find themselves at a crossroads between conservative treatment and TKA. Conservative treatments yield limited efficacy, while TKA represents a knee replacement procedure. MOWHTO offers an effective intermediate treatment option between these two approaches \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Primeau et al., found in a prospective study that performing MOWHTO in younger patients significantly reduced the risk of subsequent knee arthroplasty. Among their cohort, 79% of patients did not undergo knee arthroplasty within 10 years \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The present study exclusively enrolled KOA patients with Kellgren-Lawrence grade 3 or 4 who responded poorly to conservative treatment. This selection was made because most symptomatic patients with mild-to-moderate KOA show limited willingness to undergo surgery. Palmer et al., in a systematic review, found that in current reports, surgical outcomes for Kellgren-Lawrence grade 1 or 2 patients showed no significant difference compared to conservative management \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. However, current mainstream personalised osteotomy approaches predominantly rely on Kellgren-Lawrence grading. Feucht et al. proposed that patients with grades 1 and 2 are suitable for 50\u0026ndash;55% postoperative WBL correction, as excessive varus correction is ineffective for this group. Conversely, patients with grade 3 are suitable for postoperative WBL correction exceeding 55% \u003csup\u003e24\u003c/sup\u003e. Hohloch et al. found that the optimal postoperative WBL correction for grade 3 patients is 55\u0026ndash;60%, but with 60\u0026ndash;65% correction yielding no further improvement. Currently, we are unaware of any reports regarding MOWHTO treatment for grade 4 KOA patients \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The present study included patients with grade 3 and 4 Kellgren-Lawrence KOA, revealing significant symptom improvement in all cases. A postoperative WBL correction of 55\u0026ndash;60% proved most beneficial for patient recovery, providing practical evidence for the clinical application of MOWHTO in treating mid-to-late-stage KOA.\u003c/p\u003e \u003cp\u003eBased on preoperative planning for individualized osteotomy, multiple studies suggested that a postoperative WBL correction of 50\u0026ndash;55% is more prudent. Patients with Kellgren-Lawrence grade 3 are suitable for a postoperative WBL correction of 55\u0026ndash;60%, but excessive varus correction is not considered to yield significant symptomatic improvement \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. In the present study, patients achieving 55\u0026ndash;60% postoperative WBL correction demonstrated the best outcomes, followed by those with 60\u0026ndash;65% correction, while the poorest outcomes were observed in the 50\u0026ndash;55% group. This discrepancy primarily stems from the exclusion of Kellgren-Lawrence grade 1 and 2 patients in this study, while grade 3 and 4 patients are not entirely suitable for 50\u0026ndash;55% postoperative WBL correction. Kim et al. proposed using the highest point of the lateral intercondylar crest of the tibia as an assessment landmark for selecting the WBL, arguing that anatomical variations necessitate individualized WBL positioning based on surface landmarks \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The present study targeted the slope of the lateral intercondylar eminence as the surgical site, yielding varying degrees of postoperative WBL correction. Results indicated that correcting WBL to 55\u0026ndash;60% postoperatively yielded optimal clinical outcomes, and the 55\u0026ndash;60% WBL site coincided precisely with the vicinity of the highest point of the lateral intercondylar crest. Therefore, when using MOWHTO to treat moderate-to-severe KOA, the highest point of the lateral intercondylar crest may also be considered the ideal postoperative WBL correction site. Meanwhile, multiple studies suggested that patients with KOA accompanied by cruciate or collateral ligament injuries should not be subjected to excessive postoperative varus correction. However, there are currently no reports on the ideal postoperative WBL correction site for patients with mid-to-late-stage KOA and concomitant cruciate or collateral ligament injuries. The present study did not include such patients, necessitating further clinical investigation \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. In summary, the optimal degree of postoperative WBL correction varies among individuals and requires personalised preoperative planning based on the severity of osteoarthritis and associated injuries.\u003c/p\u003e \u003cp\u003eIn terms of the surgical approach for individualized osteotomy, the present study employed traditional techniques, including target point localization and operative instruments. Recent studies have employed modern technology for personalized osteotomy, facilitating accurate intraoperative positioning and precise control of the WBL to achieve precise bone resection. Starting with preoperative measurements, Marti et al. utilised a \"push\" radiograph technique. Based on the patient's preoperative knee anteroposterior radiograph, they employed computer simulation technology to \"push\" the affected limb into a normal mechanical position, generating a virtual radiograph with an ideal force line and an intuitive view, representing the optimal force line correction. Chernchujit et al. employed three-dimensional (3D) computer-aided design to simulate the ideal correction process, thereby determining the optimal correction angle \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. While these methods accurately determine the ideal position of individualized alignment lines, they do not enhance the precision of intraoperative osteotomy, leaving the potential for undercorrection or overcorrection. Consequently, improving the accuracy of intraoperative procedures is also a critical consideration for individualized osteotomy. Focusing on intraoperative techniques, multiple studies have demonstrated that customized instruments are emerging as a new approach to enhance the accuracy of intraoperative corrections. These technologies primarily include 3D-printed patient-specific instrumentation (PSI) and computer-assisted surgery (CAS). Cerciello et al., demonstrated through a meta-analysis that these techniques significantly reduce postoperative outliers, with PSI also effectively improves the accuracy of coronal plane correction \u003csup\u003e\u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. Zaffagnini et al. found that PSI enhances the postoperative efficacy of MOWHTO and introduced a novel personalised 3D printing technique. This technique employs Miniaci's method for digital planning based on preoperative weight-bearing X-rays and Computed Tomography(CT) scans of the lower limb. Using planning software, it generates customized screw and drill hole lengths according to individual tibial surface geometry. Medical-grade titanium alloy is then used to print the required plates and screws, thereby enhancing the accuracy of intraoperative osteotomy and lower limb alignment control \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Compared to traditional PSI, this novel personalised 3D printing technology enables surgical procedures and instruments to better align with individual patient conditions through individualized simulation of tibial anatomy, significantly improving osteotomy accuracy. Additionally, Song et al. identified CAS's advantage in effectively controlling postoperative abnormal values, with experienced practitioners also ensuring the accuracy of CAS correction \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. In summary, PSI and CAS, as cutting-edge technologies, can effectively enhance the accuracy of MOWHTO and hold promising prospects. Future prospective studies could utilise these technologies to transition from \"observing postoperative alignment correction\" to \"setting target alignment\", conducting prospective research to further determine the optimal postoperative WBL correction levels for patients with different characteristics.\u003c/p\u003e \u003cp\u003eThe limitations of this study are as follows: 1. The efficacy was observed only in patients with Kellgren-Lawrence grade 3 or 4 osteoarthritis postoperatively, without further stratification based on the severity of osteoarthritis. Future work will examine the impact of different osteoarthritis severity levels on the postoperative efficacy of MOWHTO under specific WBL conditions, based on the severity of osteoarthritis. 2. This retrospective study featured a relatively short follow-up period, lacking mid- to long-term outcomes. Future prospective cohort studies will precisely examine postoperative functional recovery and cartilage wear progression across different patient groups at multiple time points. 3. The study was confined to clinical indicators without examining biomechanical or cellular-molecular factors across groups, thus lacking deeper mechanistic investigation. Future work will establish 3D finite element models of the knee joint for different groups based on clinical findings, enabling more thorough investigation of how varying the WBL influences MOWHTO outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMOWHTO demonstrates excellent clinical efficacy in treating medial compartment KOA, serving as an effective therapeutic approach for moderate-to-severe KOA. The degree of WBL correction exhibits individual variability, with 55\u0026ndash;60% correction being considered the optimal postoperative WBL correction point for moderate-to-severe MOWHTO.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMOWHTO \u0026nbsp; \u0026nbsp; Medial open wedge high tibial osteotomy\u003c/p\u003e\n\u003cp\u003eWBL \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Weight bearing line\u003c/p\u003e\n\u003cp\u003eHKA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hip-knee-ankle\u003c/p\u003e\n\u003cp\u003eMPTA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Medial proximal tibial angle\u003c/p\u003e\n\u003cp\u003eJLCA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Joint line convergence angle\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePTSA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Posterior tibial slope angle\u003c/p\u003e\n\u003cp\u003eROM \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Range of motion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVAS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Visual analogue scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWOMAC \u0026nbsp; \u0026nbsp; \u0026nbsp;Western Ontario and McMaster Universities Osteoarthritis Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKOA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Knee osteoarthritis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eK-wires \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Kirschner wires\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTKA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total knee arthroplasty\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ep-ERK1/2 \u0026nbsp; \u0026nbsp; \u0026nbsp;Protein kinases 1/2 \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHTO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;High tibial osteotomy\u003c/p\u003e\n\u003cp\u003e3D \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Three-dimensional\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePSI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Patient-specific instrumentation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCAS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computer-assisted surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed Tomography\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the Luoyang Orthopedic Hospital of Henan Province (Orthopedic Hospital of Henan Province) for allowing us to use these data retrospectively and providing support for statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYisan Wang and Guorui Cao Interpreted the data and prepared the manuscript. Xiao Wang, Peizhao Wang, Xiaotao Shi and Mingyang Zhang Collected the data. Honglue Tan Conceptualized and designed the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eObtain funds from the following sources: Henan Provincial Key Scientific and Technological Project (252102310082); Henan Provincial Key Scientific and Technological Project (242102310025); Henan Provincial Traditional Chinese Medicine Research Special Joint Construction Project (2025LHZX5003); Henan Provincial Overseas Returnees Research Priority Funding Project (2024-11); Henan Provincial Special Research Project on Traditional Chinese Medicine (2024ZY3067); Henan Provincial Postdoctoral Research Funding Programme (365154).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data and materials used and/or analyzed during the current study are not publicly available but available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Medical Ethics Committee of Luoyang Orthopaedic Hospital (Henan Orthopaedic Hospital) (Approval No.: 2025KYKT0031-02). All patients provided informed consent and voluntarily participated in this study, signing an \u0026quot;Informed Consent Form\u0026quot;. We confirm that all methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no competing of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e College of Orthopedics, Henan University of Chinese Medicine, Zhengzhou, Henan Province, People\u0026rsquo;s Republic of China.\u003csup\u003e2\u003c/sup\u003e Department of Knee surgery, Luoyang Orthopedic Hospital of Henan Province. Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People\u0026rsquo;s Republic of China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJang S, Lee K, Ju JH. Recent Updates of Diagnosis, Pathophysiology, and Treatment on Osteoarthritis of the Knee. Int J Mol Sci. 2021;22(5):2619.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall M, van der Esch M, Hinman RS, et al. How does hip osteoarthritis differ from knee osteoarthritis? Osteoarthritis Cartilage. 2022;30(1):32\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma L. Osteoarthritis of the Knee. N Engl J Med. 2021;384(1):51\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalmer J, Getgood A, Lobenhoffer P. Medial opening wedge high tibial osteotomy for the treatment of medial unicompartmental knee osteoarthritis: A state-of-the-art review. 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Effect of different distraction gaps in open wedge high tibial osteotomy on the mechanical distribution around the knee joint: A finite element analysis and clinical validation. J Orthop Surg (Hong Kong). 2025 Sep-Dec;33(3):10225536251383123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValente G, Grenno G, Benedetti MG, Zaffagnini S, et al. Altered motor function during daily activities in patients eligible for high tibial osteotomy is primarily driven by knee varus deformity. Bone Jt Open. 2025;6(4):454\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarti CB, Gautier E, Wachtl SW, et al. Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy. 2004;20(4):366\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHohloch L, Kim S, Mehl J, et al. Customized post-operative alignment improves clinical outcome following medial open-wedge osteotomy. Knee Surg Sports Traumatol Arthrosc. 2018;26(9):2766\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeng H, Ou A, Huang X, et al. Osteotomy Around the Knee: The Surgical Treatment of Osteoarthritis. Orthop Surg. 2021;13(5):1465\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarland A, Weiss-Laxer N, Martindale M, et al. Reasons for Not Enrolling in a Randomized Clinical Trial and Patient Preferences for Knee Osteoarthritis Treatment. J Patient Exp. 2025;12:23743735251383853.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJi S, Gao Y, Zhang J, et al. High tibial lateral closing wedge and opening wedge valgus osteotomy produce different effects on posterior tibial slope and patellar height. Front Surg. 2023;10:1219614.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajgopal A, Dahiya V, Bhatnagar A, et al. Predictors of outcome following two-stage revision total knee arthroplasty. Arch Orthop Trauma Surg. 2024;144(12):5283\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalmer JS, Monk AP, Hopewell S, et al. Surgical interventions for symptomatic mild to moderate knee osteoarthritis. Cochrane Database Syst Rev. 2019;7(7):CD012128.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChernchujit B, Tharakulphan S, Prasetia R, et al. Preoperative planning of medial opening wedge high tibial osteotomy using 3D computer-aided design weight-bearing simulated guidance: Technique and preliminary result. J Orthop Surg (Hong Kong). 2019 Jan-Apr;27(1):2309499019831455.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaffagnini S, Dal Fabbro G, Belvedere C, et al. Custom-Made Devices Represent a Promising Tool to Increase Correction Accuracy of High Tibial Osteotomy: A Systematic Review of the Literature and Presentation of Pilot Cases with a New 3D-Printed System. J Clin Med. 2022;11(19):5717.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCerciello S, Ollivier M, Corona K, et al. CAS and PSI increase coronal alignment accuracy and reduce outliers when compared to traditional technique of medial open wedge high tibial osteotomy: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2022;30(2):555\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictor J, Premanathan A. Virtual 3D planning and patient specific surgical guides for osteotomies around the knee: a feasibility and proof-of-concept study. Bone Joint J. 2013;95-B(11 Suppl A):153\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones GG, Jaere M, Clarke S, et al. 3D printing and high tibial osteotomy. EFORT Open Rev. 2018;3(5):254\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElson DW, Petheram TG, Dawson MJ. High reliability in digital planning of medial opening wedge high tibial osteotomy, using Miniaci's method. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):2041\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong SJ, Bae DK, Park SH, et al. Surgical accuracy of coronal and sagittal alignment in conventional closed-wedge high tibial osteotomy after computer-assisted surgery experience. Knee Surg Relat Res. 2023;35(1):29.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"High tibial osteotomy, Weight bearing line, Correction degree, Knee osteoarthritis","lastPublishedDoi":"10.21203/rs.3.rs-8621213/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8621213/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003einvestigating the efficacy of medial open wedge high tibial osteotomy (MOWHTO) in treating medial compartment osteoarthritis of the knee under different levels of postoperative Weight bearing line (WBL) correction to identify the optimal lower limb alignment zone.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on the clinical data of 180 patients with medial compartment knee osteoarthritis treated by MOWHTO at our institution from April 2016 to November 2024. The degree of postoperative correction of the WBL was calculated using full-length radiographs of both lower limbs. Patients were categorized into three groups based on the degree of postoperative WBL correction: Group A (50\u0026ndash;55%), Group B (55\u0026ndash;60%), and Group C (60\u0026ndash;65%). Measurements of hip-knee-ankle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), and posterior tibial slope angle (PTSA) were taken at preoperative and final postoperative follow-up.Data on knee range of motion (ROM), pain visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lysholm scores were collected at preoperative and final postoperative follow-up to evaluate clinical outcomes before and after the surgery and compare clinical results among the three patient groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe average follow-up duration for the three groups was approximately 39 months, with no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The postoperative HKA and MPTA in the three groups were significantly higher than preoperative levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). PTSA and JLCA showed no significant difference compared to preoperative measurements (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).At the final postoperative follow-up, ROM, VAS, WOMAC scores, and Lysholm scores were all significantly improved compared to preoperative levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Comparing the three groups, patients in Group B demonstrated the most favourable outcomes in ROM (P\u0026thinsp;=\u0026thinsp;0.013), VAS (P\u0026thinsp;=\u0026thinsp;0.010), WOMAC score (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and Lysholm score (P\u0026thinsp;=\u0026thinsp;0.004), while patients in Group C had the worst outcomes for these parameters. These differences were statistically significant. There were no statistically significant differences in the postoperative thrombosis incidence or wound complication rates among the three groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCorrecting the WBL to within the 50\u0026ndash;65% range can effectively improve knee function by optimizing the distribution of lower limb alignment. The procedure is considered safe. Among the three groups, Correcting the WBL to 55\u0026ndash;60% yielded the most significant improvement in knee function, while the range of 50\u0026ndash;55% produced the weakest effect.\u003c/p\u003e","manuscriptTitle":"Analysis of the Efficacy of High Tibial Osteotomy in Treating Knee Osteoarthritis at Different Levels of Weight Bearing Line Correction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 13:06:40","doi":"10.21203/rs.3.rs-8621213/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-28T12:12:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-17T01:42:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-17T01:41:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2026-01-16T17:06:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5015e7ba-25b2-46d1-964c-1266fcc98cc1","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-30T13:06:41+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 13:06:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8621213","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8621213","identity":"rs-8621213","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}