Research trends and hotspots of alignment in high tibial osteotomy: a bibliometric analysis

Research trends and hotspots of alignment in high tibial osteotomy: a bibliometric analysis | 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 Systematic Review Research trends and hotspots of alignment in high tibial osteotomy: a bibliometric analysis Shuo Zhang, Xiaoyu Li, Lin Shen, Weidong Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7718491/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To analyze the literature on lower limb alignment in high tibial osteotomy, highlighting development trends, the current research status, and potential emerging frontiers. Methods A comprehensive search was conducted in the Web of Science Core Collection for literature on lower limb alignment in high tibial osteotomy, covering the period from January 1, 1981, to June 30, 2025. Bibliometric tools, including VOSviewer, R Bibliometrix, and CiteSpace, were employed to assess the research landscape and evaluate core authors, journals, and contributing countries. Keyword co-occurrence and cluster analyses were performed to identify global research trends and hotspots. Results A total of 1270 articles published between January 1981 and June 2025 were included, showing a gradual increase in annual publications. Knee Surgery Sports Traumatology Arthroscopy presented the highest publication volume and influence. Lee YS was the most prolific author. Western University in Canada was the most productive institution. South Korea contributed the most publications, followed by the United States, which demonstrated the most extensive international collaboration network. Current research focuses primarily on patellar height changes, gait analysis, and open-wedge high tibial osteotomy. Future research trends are expected to concentrate on long-term outcomes, individualized strategies, and artificial intelligence-assisted planning and navigation. Conclusion In recent years, significant advancements have been achieved in research on alignment in HTO. With increasing patient expectations regarding long-term surgical outcomes, there is a growing imperative for systematic long-term follow-up and evaluation of postoperative alignment changes. The optimization of individualized treatment strategies has emerged as a pivotal direction for enhancing surgical efficacy. The integration of artificial intelligence into surgical planning and navigation holds substantial promise for improving operative accuracy, patient satisfaction, and overall success rates. Collectively, these developments are expected to catalyze higher-quality research and yield superior clinical solutions for HTO. Bibliometric analysis High tibial osteotomy Alignment Research trends Research hotspots Figures Figure 1 Figure 2 Figure 3 Introduction Knee osteoarthritis (KOA) is a degenerative joint disease characterized by high incidence and disability rates [1] . The global prevalence of KOA among adults is approximately 16%, which increases significantly with age [2] . Approximately 30% of patients eventually progress to disability owing to symptom deterioration, and KOA constitutes nearly 80% of the global osteoarthritis burden [3–5] , severely reducing patients' quality of life and imposing a heavy socioeconomic burden. Projections indicate that the number of people affected by KOA worldwide will increase by 74.9% from 2020–2050 [6] . Against the backdrop of a continuously aging population, the prevalence of KOA is expected to continue to rise, making its prevention and treatment a major challenge in the field of global public health [7–8] . Currently, surgical interventions for KOA primarily include total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and high tibial osteotomy (HTO). While TKA and UKA demonstrate reliable outcomes in elderly patients, HTO is often considered the preferred joint-preserving procedure for younger, highly active patients with malalignment, as it preserves the native joint structure, corrects biomechanical alignment, and delays the progression of arthritis [9–10] . Since its first description by Jackson and Waugh in 1961 [11] , the technique has undergone standardized procedural refinements and continuous improvements in internal fixation devices. It is now widely used in young, active patients with varus KOA and has demonstrated favorable clinical outcomes. The mechanism of HTO involves shifting the weight-bearing axis to the lateral compartment of the knee, thereby reducing excessive load on the medial compartment [12] . This alleviates knee pain, improves functional mobility, slows osteoarthritis progression, and may delay or even prevent the need for knee arthroplasty [13] . The key to successful HTO lies in accurate intraoperative achievement of the preoperative planning objectives. Among these factors, the target mechanical axis correction angle and the osteotomy opening width are the most critical factors influencing surgical success and long-term outcomes [14–16] . Despite numerous technical advances, a certain degree of correction error remains common after HTO. Studies indicate that only approximately 70%-80% of cases achieve postoperative alignment within the target range postoperatively. Lee et al. [17] emphasized that periarticular soft tissue laxity significantly affects the accuracy of alignment correction, making it difficult to completely avoid deviations even with strict adherence to the preoperative plan. Mabrouk et al. [18] further highlighted that maintaining the posterior tibial slope and patellar height is crucial for stability during medial open-wedge HTO, as changes in these parameters can lead to under- or overcorrection. Additionally, Kiliçli and Taşkiran [19] reported rare but serious cases of postoperative valgus deformity, suggesting that individual anatomical variations and soft tissue imbalance may be important contributors to correction inaccuracies. Bibliometrics is an interdisciplinary field that integrates mathematics, statistics, and information science, enabling multidimensional quantitative assessment of research dynamics in specific domains [20] . A standardized analytical framework has been established within medical research [21] . High tibial osteotomy, as a cornerstone of knee-preserving treatment, has garnered increasing clinical attention. Although the precision of lower limb alignment correction is widely recognized as a critical factor influencing HTO outcomes [14–16] , a systematic bibliometric analysis is lacking. Existing reviews are largely confined to qualitative descriptions and lack quantitative evidence derived from scientometric visualization methods. Previous studies have often focused on isolated influencing factors, failing to systematically examine the principles of alignment change and its relationship with multidimensional outcome measures. Therefore, this study integrates bibliometric and visual analysis techniques to systematically outline development trends and emerging research hotspots in the field of lower limb alignment in HTO, with the aim of providing a reference for future investigations. Materials and methods After determining the search strategy and consulting MeSH terms from PubMed, a search was performed through the Web of Science Core Collection (WoSCC) database. The search strategy was as follows: (TS = ("high tibial osteotomy" OR "hto" OR "tibial osteotomy" OR "open wedge osteotomy" OR "opening wedge osteotomy" OR "closed wedge osteotomy" OR "closing wedge osteotomy") AND TS = ("weight bearing line" OR "alignment" OR "mechanical axis")). The search was completed on June 30, 2025, at 17:20:32 (GMT + 0800, CST), yielding a total of 1,270 relevant articles from January 1981 to June 2025. The retrieved data were imported into Microsoft Excel 2019 for initial organization and collation. The Bibliometrix package in R 4.3.2 was then used for publication statistics and journal source analysis. VOSviewer 1.6.20 and Scimago Graphica 1.0.51 were used for national collaboration network analysis. CiteSpace 6.3. R1 was used for author and institutional collaboration analysis, as well as co-occurrence, clustering, and burst analysis of keywords. Results Publication Volume and Temporal Trends A total of 1270 publications were retrieved, including 1210 research articles and 60 reviews. Research on alignment in HTO has demonstrated a continuous growth trend over the past decades. The surge in publication volume underscores the growing recognition of the importance of alignment in HTO research. Before 2001, research in this field was in its infancy, with fewer than 10 annual publications, indicating relatively limited academic attention (these publications were not included in Fig. 1A because of the small number). After 2018, exponential growth occurred, with an average annual growth rate of 22.1%, exceeding 100 publications by 2022. This surge reflects the widespread recognition of the importance of alignment issues in HTO and the increasingly strong link between research interest and clinical needs. Country/Region Distribution The top 10 countries in terms of publication numbers are shown in Fig. 1B. South Korea contributed the greatest number of publications (n=540, 42.5%), followed by the United States (n=479, 37.7%) and Japan (n=398, 31.3%). These three countries have made outstanding contributions to the number of publications in the field of HTO alignment. Research institutions from 48 countries and regions have published relevant results over time. These articles were published in 175 journals and involved 4318 authors. On the basis of information extracted from published articles, a world map was created to show collaborative research between different countries (Fig. 1C). Each circle represents a country, with size proportional to publication output; larger circles indicate greater contributions. The connecting lines between circles represent relationships between countries, with thicker lines indicating closer connections. As shown, the United States has the most extensive collaborative relationships with other countries. Institutional Distribution A total of 1164 institutions contributed publications. As shown in Fig. 1D, the top three institutions by publication volume were Western University, Canada (77 articles); Assistance Publique-Hôpitaux de Marseille, France (45 articles); and Seoul National University, South Korea (45 articles). Author Contributions A total of 4318 authors contributed to the relevant literature. As shown in Fig. 2A, the top three authors by publication volume were Lee YS (29 articles), Ollivier M (28 articles), and Birmingham TB (27 articles). A high-impact article published by Lee YS in 2022 evaluated the impact of different medial proximal tibial angles (MPTAs), representing joint line obliquity (JLO), on midterm radiographic and clinical outcomes after MOWHTO, suggesting that an MPTA exceeding 95.2 degrees is associated with poorer clinical outcomes [22] . As shown in Fig. 2B, the size of each node represents the annual output of individual authors, whereas the color depth indicates the total number of citations per year. Authors such as Lee YS, who demonstrate consistent or periodic high productivity, represent active leading forces in orthopedic research. Further observation reveals that some authors not only have stable paper output but also show an increasing trend in citations, suggesting high research quality and continuously expanding influence. The work of such authors may provide important references for future clinical practice and scientific research. Analysis of Productive Journals Fig. 2C shows a visualization map of productive journals. In the visual map, each node represents a journal, its size is proportional to the number of publications, node colors distinguish different research themes or clusters, and lines between nodes indicate collaboration or citation relationships between journals. More lines indicate higher citation frequency or stronger collaboration for papers published in that journal. Knee Surgery, Sports Traumatology, and Arthroscopy had the highest total citation frequency.As shown in Fig. 2D, the top 10 journals published 598 articles, accounting for approximately 47.08% of the total publications. Knee Surgery, Sports Traumatology, and Arthroscopy published the most articles (186), followed by Knee and the American Journal of Sports Medicine. This provides a reference for subsequent literature retrieval and journal influence evaluation in the field. Keyword Analysis A total of 1428 keywords were identified. Fig. 3A shows the keyword co-occurrence network. Lines between nodes represent cooccurrences between different keywords. Each node represents a keyword. The circle size represents the frequency of occurrence. Different colors represent different clusters. Fig. 3B shows the top ten keywords were osteoarthritis, knee, alignment, high tibial osteotomy, follow-up, slope, arthritis, joint, long-term, and arthroplasty. A keyword burst detection analysis was subsequently conducted. Keywords with the highest burst strength usually indicate emerging hotspots in the field during specific time periods. Keywords that burst earlier represent areas that have been focused on in previous research and may have established a certain research foundation, whereas keywords that burst recently indicate research directions with significantly increased attention at the current stage, potentially representing emerging research hotspots. As shown in Fig. 3C, the top five keywords by burst strength and their corresponding burst strengths were "long term" (17.77), "knee osteoarthritis" (11.03), "varus knee osteoarthritis" (10.91), "osteoarthritis" (9.18), and "conventional technique" (6.95). From a temporal perspective, the earliest bursting keywords were "arthritis" and "walking". The most recent bursting keywords included "varus", "overcorrection", "limb alignment", "joint line obliquity", "knee osteoarthritis", and "open-wedge high tibial osteotomy". Fig. 3D presents a timeline view constructed on the basis of keyword co-occurrence analysis, which visualizes the distribution and evolution of keywords over time. The size of the nodes is proportional to the frequency of keyword occurrence, with larger nodes indicating that the term is more common in the overall research literature. Keywords located on the right side of the timeline with larger node sizes often represent currently focused research topics. Keyword clustering can describe the knowledge structure and research topic distribution in a specific research field. Fig. 3E shows that keywords in the field of HTO alignment can be divided into seven clusters: "patellar height", "high tibial osteotomy", "gait", "supramalleolar osteotomy", "tibia vara", "open-wedge high tibial osteotomy", and "unicompartmental knee arthroplasty". Discussion This study employed bibliometric and visual analysis to provide a comprehensive analysis of the current status and future trends in HTO alignment research. An analysis of the contributions of different countries, institutions, journals, and authors to research in this field identified emerging research directions and provided references for future research in this area. In recent years, the number of publications related to HTO alignment has increased significantly [23] , reflecting the growing importance attached to HTO as a key joint-preserving technology [24,25] . The increasing prevalence of KOA, driven by population aging, patients' expectations for greater functional recovery and delayed joint replacement, and improvements in HTO surgical techniques have collectively driven the vigorous development of this field. With continued attention to medium- and long-term efficacy and personalized precision treatment needs in HTO, research interest in this field is expected to remain high in the future. National analysis reveals that South Korea leads in publication volume, which may be attributed to the widespread adoption of knee-preservation concepts, its advantages in orthopedic technology development, and a robust academic output system. Although the United States trails slightly in publication numbers, its extensive international collaboration network (Figure 3) underscores its role as a global research hub. The rapid rise of China (ranking fourth) is also noteworthy. These findings suggest that research teams from different countries should actively pursue international collaboration, integrate complementary resources, and make concerted efforts to address the pivotal challenges in achieving precise mechanical axis alignment during HTO. In terms of institutions, Western University in Canada and Assistance Publique-Hôpitaux de Marseille in France are leading institutions in HTO alignment research. The continuous output of high-level results has laid a solid foundation for progress in this field. Researchers may consider collaborating with these institutions to deepen related research. Author analysis indicates that Lee YS, as the most prolific author, has focused his research on postoperative radiographic evaluation, complications, and influencing factors of HTO, making important contributions to deepening the biomechanical understanding of HTO alignment correction and optimizing surgical plans. Monitoring the recent contributions of these core research teams and leading authors is an effective strategy for updating field developments. Journal analysis revealed that Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) leads significantly in both publication volume and total citation frequency, fully demonstrating its authority as a top journal in sports medicine and arthroscopic surgery in the research field of HTO, a core joint-preserving technology. High-impact journals such as the American Journal of Sports Medicine (AJSM) and Knee constitute the main platforms for core knowledge dissemination and exchange in this field. Researchers should focus on these core publications when tracking cutting-edge progress and selecting target journals. The strong influence of KSSTA and AJSM also reflects that current research tends to be published in comprehensive journals focusing on sports medicine, arthroscopy, and knee surgery. A detailed analysis of keyword co-occurrence results helps us grasp the hot topics in HTO alignment research. Cluster 1 is "patellar height". Open-wedge high tibial osteotomy may lead to decreased patellar height postoperatively [26] and cause anterior knee pain and limited activity [27] . Excessive valgus correction can lead to poor patellar tracking during knee flexion [28] . Kim et al. [29] reported signs of patellofemoral joint cartilage deterioration during second-look arthroscopy approximately two years after open-wedge high tibial osteotomy. To address this issue, modified techniques to maintain patellar height have been proposed [30] . Horikawa et al. [31] reported that this technique can effectively maintain preoperative and postoperative patellar height. Cluster 2 is "gait". Three-dimensional gait analysis confirmed that HTO can not only effectively restore lower limb static alignment but also significantly reshape the dynamic gait biomechanical characteristics of patients with knee osteoarthritis [32] . The main changes caused by open-wedge high tibial osteotomy are concentrated in the coronal plane, manifested as a significant reduction in the peak knee adduction moment and impulse [33] . Notably, postoperative alterations in gait kinetics and kinematics following HTO are three-dimensional. In addition to reduced knee adduction in the coronal plane, significant changes may also be observed in the sagittal and horizontal planes [34] . A deep understanding of these three-dimensional biomechanical changes is crucial for developing individualized, evidence-based postoperative rehabilitation programs. Future research needs to clarify whether significant changes in the sagittal and horizontal planes are the result of redistributed knee joint load or insufficient postoperative rehabilitation intervention [35] . According to keyword burst analysis, long-term efficacy, individualized correction strategies and artificial intelligence-assisted planning and navigation may be research trends in the field of HTO alignment research. Achieving optimal alignment correction is the core goal of HTO, but other anatomical factors need to be considered comprehensively. Tibial factors account for only approximately 30% of varus knee deformities [36] . Correcting only the proximal tibia may lead to nonphysiological joint line obliquity (JLO) [37] . Studies have shown that a JLO exceeding 5° significantly increases shear stress on the tibial articular cartilage [38] , whereas a JLO exceeding 4° is significantly associated with a poorer Knee Society objective score and function score [39] . The medial proximal tibial angle (MPTA) is a key radiographic parameter for predicting postoperative JLO. Nakayama et al. [38] proposed that an MPTA of 95° corresponds to a JLO of 5°. Oh et al. [40] reported that patients with severe varus requiring large-angle correction are more likely to have a JLO >4°. Therefore, when preoperative planning predicts that the MPTA exceeds 95° or that the JLO exceeds 4–5°, the applicability of HTO alone should be carefully evaluated, and alternative options such as biplanar osteotomy may be considered [40] . Overcorrection (valgus overcorrection) is a complication that requires vigilance in HTO, especially when long-term efficacy is pursued, and its adverse effects are increasingly recognized [41-46] . Overcorrection not only affects appearance and patient satisfaction [41] but also significantly alters knee biomechanics, increases lateral compartment load, accelerates the progression of lateral osteoarthritis [42] , disrupts patellofemoral joint stability, increases the risk of patellar instability and dislocation, and accelerates patellofemoral joint cartilage and meniscal degeneration, worsening anterior knee pain [43] . Multiple studies have confirmed that overcorrection is significantly associated with accelerated patellar degeneration and poorer clinical outcomes postoperatively [44-46] . Furthermore, knees with excessive valgus may increase the difficulty of ligament balance during subsequent total knee arthroplasty (TKA) [47] . These risks highlight the importance of achieving precise alignment control while pursuing long-term efficacy of HTO to avoid the negative effects of overcorrection [48] . Given that HTO is mainly suitable for relatively young, highly active patients with knee osteoarthritis [49] , its long-term efficacy is naturally a core concern for both doctors and patients. Although multiple studies have demonstrated that HTO effectively alleviates pain and improves knee function in the short to medium term, a subset of patients may eventually require TKA due to disease progression [50-51] . This raises an important clinical question: are the clinical outcomes of TKA performed after failed HTO inferior to those of primary TKA [52] . The existing evidence shows some heterogeneity. A meta-analysis suggested that, compared with primary TKA, TKA after failed HTO may be associated with a longer operation time, potential limitations in functional recovery, and greater risks of infection and revision [53] . However, some studies have reported no significant differences in standardized clinical scores or range of motion between the two groups of patients [54] . As the global burden of osteoarthritis continues to increase, the need for long-term studies to clarify the potential impact of HTO on subsequent TKA is becoming increasingly prominent. Therefore, evaluating the long-term efficacy of HTO and its potential impact on patients who eventually undergo TKA remains an important research direction and is directly related to patients' long-term quality of life and joint function. Despite continuous improvements in surgical techniques, unexpected correction errors still occur after HTO [17-19] . Some studies report that only 70%–80% of alignments are within the target range postoperatively [55,56] . To improve accuracy, various personalized correction schemes based on patient-specific factors have been proposed. Jakob et al. [57] suggested directly adjusting the target on the basis of the depth of medial compartment cartilage wear. Muller et al. [58] proposed a method for correction on the basis of the difference in cartilage softening between the medial and lateral compartments. Feucht et al. [59] also introduced a personalized scheme for adjusting the valgus angle on the basis of the patient's Kellgren–Lawrence grade of arthritis. In summary, in clinical practice, comprehensively considering the cartilage status, patient expected activity level, age, arthritis severity, and other key decision factors to achieve individualized precise correction is recommended. Advancements in surgical technology have significantly improved the safety and precision of HTO. Intraoperative navigation technology and 3D-printed personalized osteotomy guides are representative technological innovations [60-62] . Numerous studies have confirmed the clinical advantages of 3D-printed individualized osteotomy guides. Research shows that these methods can simplify surgical steps, shorten the learning curve and operation time, and reduce the need for intraoperative fluoroscopy [63-65] , which is especially beneficial for handling complex deformities. Some meta-analyses also indicate [66-68] that navigation-assisted methods further improve correction accuracy by reducing outliers in alignment correction, providing real-time feedback, and better maintaining the posterior tibial slope, among other advantages. Mid-term follow-up also yields satisfactory clinical outcomes [69] . On this basis, we advocate combining AI preoperative planning with 3D-printed guides and intraoperative navigation to achieve real-time control of alignment, further enhancing the precision and success rate of HTO surgery. This study used bibliometric methods to systematically analyze the research status, main contributors, current research hotspots, and possible future research directions in the field of HTO alignment from 1981--2025. However, it inevitably has several limitations. First, during the literature retrieval process, the coverage of the literature in this study may have had a certain degree of incompleteness due to the selection range and precision of the search terms. Second, all bibliometric data included in this study came from the WoSCC database, ignoring other large databases. Some relevant literature contained in other databases may have been unavoidably omitted. However, the WoSCC is one of the most comprehensive and authoritative database platforms for obtaining global academic information and is considered the best database for bibliometric analysis. Furthermore, different databases have different characteristics, including different file output formats and citation calculation methods. Combining multiple databases may not be the best option. Finally, this study analyzed only English publications, potentially overlooking high-quality non-English articles. Moreover, the continuous updating of online databases may introduce bias into our bibliometric analysis results. These limitations will be addressed in future research. Conclusion Current research in this field has focused primarily on patellar height alterations, gait analysis, and open-wedge high tibial osteotomy. The research landscape is dominated by South Korea, followed by the United States and Japan, with China rising rapidly. Enhancing international collaboration is crucial for driving more profound research developments in the future. On the basis of keyword burst analysis, clustering, and temporal evolution analysis, future research should pay more attention to long-term efficacy evaluation, the development and validation of personalized precision correction schemes on the basis of multiple factors, and the deep integration of artificial intelligence (AI) technology to improve surgical accuracy and efficiency. These findings provide important references for researchers to grasp the context of the field, focus on key scientific issues, and optimize clinical practice. Declarations Acknowledgments We would like to express our sincere gratitude to Xiaoyu Li, Weidong Xu for their invaluable guidance, support, and encouragement throughout this research. Their expertise and insights have greatly contributed to the success of this study. We would also like to thank the anonymous reviewers and the editorial board for their valuable comments and suggestions, which have signifificantly improved the quality of this manuscript. Authors’ contributions Writing – original draft: Shuo Zhang, Xiaoyu Li, Lin Shen Writing – review & editing: Weidong Xu These authors contributed equally:Shuo Zhang, Xiaoyu Li, Lin Shen Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability No datasets were generated or analysed during the current study. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable Competing interests The authors declare no competing interests. Clinical trial number Not applicable. Author details 1 Department of Orthopedics, Shanghai Changhai Hospital, Shanghai, China 2 Department of Orthopedics, Shanghai Changhai Hospital, Shanghai, China 3 Department of Outpatient, Shanghai Changzheng Hospital, Shanghai, China *Correspondence: Weidong Xu e-mail: [email protected] References Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019;393(10182):1745-1759. Cui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional incidence, incidence and risk factors for knee osteoarthritis in population-based studies. EClinicalMedicine. 2020;29-30:100587. Safiri S, Kolahi AA, Smith E, et al. Global, regional and national burden of osteoarthritis 1990-2017: a systematic analysis of the Global Burden of Disease Study 2017. Ann Rheum Dis. 2020;79(6):819-828. Liu Q, Wang S, Lin J, et al. The burden for knee osteoarthritis among Chinese elderly: estimates from a nationally representative study. Osteoarthritis Cartilage. 2018;26(12):1636-1642. Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. JAMA. 2021;325(6):568-578. GBD 2021 Osteoarthritis Collaborators. Global, regional, and national burden of osteoarthritis, 1990--2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(9):e508-e522. Sharma L. Osteoarthritis of the knee. N Engl J Med. 2021;384(1):51-59. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-1330. Jackson JP, Waugh W. Tibial Osteotomy for Osteoarthritis of the Knee. Proc R Soc Med. 1960;53(10):888. Song SJ, Yoon KH, Park CH. Patellofemoral Cartilage Degeneration After Closed- and Open-Wedge High-Tibial Osteotomy with Large Alignment Correction. Am J Sports Med. 2020;48(11):2718-2725. Dal Fabbro G, Grassi A, Agostinone P, et al. High survivorship rate and good clinical outcomes after high tibial osteotomy in patients with radiological advanced medial knee osteoarthritis: a systematic review. Arch Orthop Trauma Surg. 2024;144(9):3977-3988. Agneskirchner JD, Hurschler C, Wrann CD, et al. The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy. 2007;23(8):852-861. Bode L, Eberbach H, Brenner AS, et al. 10-Year Survival Rates After High Tibial Osteotomy Using Angular Stable Internal Plate Fixation: Case Series With Subgroup Analysis of Outcomes After Combined Autologous Chondrocyte Implantation and High Tibial Osteotomy. Orthop J Sports Med. 2022;10(2):23259671221078003. Engel GM, Lippert FG. Valgus tibial osteotomy: avoiding pitfalls. Clin Orthop Relat Res. 1981;(160):137-143. Kang Y, Kim J, Sim JA, et al. Stress Effect in the Knee Joint Based on the Fibular Osteotomy Level and Varus Deformity: A Finite Element Analysis Study. Bioengineering. 2023;10(9):1003. Lind-Hansen TB, Lind MC, Nielsen PT, et al. Open-Wedge High Tibial Osteotomy: RCT 2 Years RSA Follow-Up. J Knee Surg. 2016;29(8):664-672. Lee DH, Park SC, Park HJ, et al. Effect of soft tissue laxity of the knee joint on limb alignment correction in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3704-3712. Mabrouk A, An JS, Fernandes LR, et al. Maintaining Posterior Tibial Slope and Patellar Height During Medial Opening Wedge High Tibial Osteotomy. Orthop J Sports Med. 2023;11(12):23259671231213595. Kiliçli B, Taşkiran E. A Rare Complication: Severe Valgus Deformity After Open-Wedge High Tibial Osteotomy. J Orthop Case Rep. 2024;14(4):84-89. Bornmann L, Leydesdorff L. Scientometrics in a changing research landscape: bibliometrics has become an integral part of research quality evaluation and has been changing the practice of research. EMBO Rep. 2014;15(12):1228-1232. Chiu WT, Ho YS. Bibliometric analysis of tsunami research. Scientometrics. 2007;73(1):3-17. Kim JS, Lim JK, Choi HG, et al. Excessively Increased Joint-Line Obliquity After Medial Opening-Wedge High Tibial Osteotomy Is Associated With Inferior Radiologic and Clinical Outcomes: What Is Permissible Joint-Line Obliquity. Arthroscopy. 2022;38(6):1904-1915. Ma XL, Hu YC, Wang KZ, et al; Chinese Hospital Association Clinical Medical Technology Application Committee. Chinese clinical practice guidelines in treating knee osteoarthritis by periarticular knee osteotomy. Orthop Surg. 2022;14(5):789-806. Huang Y, Lobenhoffer P, Jiang XY. Development of knee-preserving osteotomy in China. Sci Bull. 2023;68(2):125-128. Hoorntje A, Witjes S, Kuijer P, et al. High rates of return to sports activities and work after osteotomies around the knee: a systematic review and meta-analysis. Sports Med. 2017;47(11):2219-2244. Bin SI, Kim HJ, Ahn HS, Rim DS, Lee DH. Changes in patellar height after opening wedge and closing wedge high tibial osteotomy: a meta-analysis. Arthroscopy. 2016;32(11):2393-2400. Stoffel K, Willers C, Korshid O, Kuster M. Patellofemoral contact pressure following high tibial osteotomy: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. 2007;15(9):1094-1100. Lee SS, So SY, Jung EY, Kim HJ, Lee BH, Wang JH. Predictive factors for patellofemoral degenerative progression after opening-wedge high tibial osteotomy. Arthroscopy. 2019;35(6):1703-1710. Kim KI, Kim DK, Song SJ, Lee SH, Bae DK. Medial open-wedge high tibial osteotomy may adversely affect the patellofemoral joint. Arthroscopy. 2017;33(4):811-816. Gaasbeek R, Sonneveld H, Van Heerwaarden R, Jacobs W, Wymenga A. Distal tuberosity osteotomy in open wedge high tibial osteotomy can prevent patella infera: a new technique. Knee. 2004;11(6):457-461. Horikawa T, Kubota K, Hara S, Akasaki Y. Distal tuberosity osteotomy in open-wedge high tibial osteotomy does not exacerbate patellofemoral osteoarthritis on arthroscopic evaluation. Knee Surg Sports Traumatol Arthrosc. 2020;28(6):1750-1756. Senior D. Qualisys medical AB: Qualisys Track Manager user manual. Gothenburg: NRC Publications Archive (NPArC); 2004. Getgood A, Collins B, Slynarski K, et al. Short-term safety and efficacy of a novel high tibial osteotomy system: a case controlled study. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):260-269. Lee DW, Han HS, Ro DH. Comparative gait analysis: Similar coronal but different sagittal effects between closing-wedge and opening-wedge high tibial osteotomies. Clin Biomech. 2024;114:106238. da Silva HGPV, Zorzi AR, da Silva HPV, et al. Gait analysis in short-term follow-up of medial opening wedge high tibial osteotomy. Eur J Orthop Surg Traumatol. 2028;28(5):939-946. Hofmann S, Lobenhoffer P, Staubli A, Van Heerwaarden R. Osteotomies of the knee joint in patients with monocompartmental arthritis. Orthopade. 2009;38(8):755-769. Takeuchi R, Ishikawa H, Aratake M, et al. Medial opening wedge high tibial osteotomy with early full weight bearing. Arthroscopy. 2009;25(1):46-53. Nakayama H, Schröter S, Yamamoto C, et al. Large correction in opening wedge high tibial osteotomy with resultant joint-line obliquity induces excessive shear stress on the articular cartilage. Knee Surg Sports Traumatol Arthrosc. 2018;26(6):1873-1878. Song JH, Bin SI, Kim JM, Lee BS. What is the acceptable limit of joint-line obliquity after medial open wedge high tibial osteotomy? Analysis on the basis of the midterm results. Am J Sports Med. 2020;48(12):3028-3035. Oh KJ, Ko YB, Bae JH, Yoon ST, Kim JG. Analysis of knee joint line obliquity after high tibial osteotomy. J Knee Surg. 2016;29(8):649-657. 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):e21.00141. Yoon TH, Choi CH, Kim SJ, et al. Effect of Medial Open-Wedge High Tibial Osteotomy on the Patellofemoral Joint According to Postoperative Realignment. Am J Sports Med. 2019;47(8):1863-1873. Yin Y, Li S, Zhang R, et al. What is the relationship between the “Fujisawa point” and postoperative knee valgus angle? A theoretical, computer-based study. Knee. 2020;27(1):183-191. Lee SS, So SY, Jung EY, et al. Predictive Factors for Patellofemoral Degenerative Progression After Opening-Wedge High Tibial Osteotomy. Arthroscopy. 2019;35(6):1703-1710. Song SJ, Bae DK, Kim KI, et al. Conversion Total Knee Arthroplasty after Failed High Tibial Osteotomy. Knee Surg Relat Res. 2016;28(2):89-98. 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):e21.00141. Kim KI, Lee SH, Kim JH. The presence or absence of cartilage regeneration following medial open-wing high-tibial osteotomy does not predict long-term outcomes. Arthroscopy. 2025;S0749-8063(25)00493-1. Ayet CAB, Mancino F, Lim YP, et al. Satisfactory 10-year survivorship of medial opening wedge high tibial osteotomy for isolated medial compartment osteoarthritis and varus alignment: An analysis from a high-volume institution. Knee Surg Sports Traumatol Arthrosc. 2025;33(5):1804-1814. Sharma L. Osteoarthritis of the Knee. N Engl J Med. 2021;384(1):51-59. Schröter S, Mueller J, van Heerwaarden R, et al. Return to work and clinical outcome after open wedge HTO. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):213-219. Whatling GM, Biggs PR, Elson DW, et al. High tibial osteotomy results in improved frontal plane knee moments, gait patterns and patient-reported outcomes. Knee Surg Sports Traumatol Arthrosc. 2020;28(9):2872-2882. Robertsson O, W-Dahl A. The risk of revision after TKA is affected by previous HTO or UKA. Clin Orthop Relat Res. 2015;473(1):90-93. Shen G, Shen D, Fang Y, et al. Clinical Outcomes of Revision Total Knee Arthroplasty after High Tibial Osteotomy and Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-Analysis. Orthop Surg. 2022;14(8):1549-1557. Bae DK, Song SJ, Park CH, Liang H, Bae JK. Comparison of midterm results between conversion total knee arthroplasties following closed wedge high tibial osteotomy and primary total knee arthroplasties: A matched pair study including patellar symptoms and position. J Orthop Sci. 2017;22(3):495-500. Gebhard F, Krettek C, Hüfner T, et al. Reliability of computer-assisted surgery as an intraoperative ruler in navigated high tibial osteotomy. Arch Orthop Trauma Surg. 2011;131(3):297-302. Wang G, Zheng G, Keppler P, et al. Implementation, accuracy evaluation, and preliminary clinical trial of a CT-free navigation system for high tibial opening wedge osteotomy. Comput Aided Surg. 2005;10(2):73-86. Jakob RP, Jacobi M. Closing wedge osteotomy of the tibial head in treatment of single compartment arthrosis. Orthopade. 2004;33(2):143-152. Müller M, Strecker W. Arthroscopy prior to osteotomy around the knee? Arch Orthop Trauma Surg. 2008;128(11):1217-1221. 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):2273-2280. 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. Aman ZS, DePhillipo NN, Peebles LA, et al. Improved Accuracy of Coronal Alignment Can Be Attained Using 3D-Printed Patient-Specific Instrumentation for Knee Osteotomies: A Systematic Review of Level III and IV Studies. Arthroscopy. 2022;38(9):2741-2758. Kyung BS, Kim JG, Jang KM, et al. Are navigation systems accurate enough to predict the correction angle during high tibial osteotomy? Comparison of navigation systems with 3-dimensional computed tomography and standing radiographs. Am J Sports Med. 2013;41(10):2368-2374. Van Genechten W, Van Tilborg W, Van den Bempt M, et al. Feasibility and 3D Planning of a Novel Patient-Specific Instrumentation Technique in Medial Opening-Wedge High Tibial Osteotomy. J Knee Surg. 2021;34(14):1560-1569. Jacquet C, Sharma A, Fabre M, et al. Patient-specific high-tibial osteotomy’s “cutting-guides” decrease operating time and the number of fluoroscopic images taken after a Brief Learning Curve. Knee Surg Sports Traumatol Arthrosc. 2020;28(9):2854-2862. Donnez M, Ollivier M, Munier M, et al. Are three-dimensional patient-specific cutting guides for open wedge high tibial osteotomy accurate? An in vitro study. J Orthop Surg Res. 2018;13(1):171. Kim HJ, Yoon JR, Choi GW, et al. Imageless Navigation Versus Conventional Open Wedge High Tibial Osteotomy: A Meta-Analysis of Comparative Studies. Knee Surg Relat Res. 2016;28(1):16-26. Yan J, Musahl V, Kay J, et al. Outcome reporting following navigated high tibial osteotomy of the knee: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24(11):3529-3555. Nha KW, Shin YS, Kwon HM, et al. Navigated versus Conventional Technique in High Tibial Osteotomy: A Meta-Analysis Focusing on Weight Bearing Effect. Knee Surg Relat Res. 2019;31(2):81-102. Hasegawa M, Naito Y, Tone S, et al. Correction to: High rates of outliers in computer-assisted high tibial osteotomy with excellent mid-term outcomes. Knee Surg Sports Traumatol Arthrosc. 2023;31(2):406. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-7718491","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":520927541,"identity":"76e0129e-8f5c-4126-bfaf-c5e9c10ab7e1","order_by":0,"name":"Shuo Zhang","email":"","orcid":"","institution":"Shanghai Changhai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shuo","middleName":"","lastName":"Zhang","suffix":""},{"id":520927542,"identity":"3c4268c7-3fbd-46d0-b3fb-c6f84e5e2bac","order_by":1,"name":"Xiaoyu Li","email":"","orcid":"","institution":"Shanghai Changzheng Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyu","middleName":"","lastName":"Li","suffix":""},{"id":520927543,"identity":"76d24601-5f23-4439-8925-d654f0e5a636","order_by":2,"name":"Lin Shen","email":"","orcid":"","institution":"Shanghai Changzheng Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Shen","suffix":""},{"id":520927544,"identity":"ff6f9b6a-c25c-45d2-bb54-3138887acabf","order_by":3,"name":"Weidong Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYHACA2YwycDY+CChooY0Lc0GD84cI0kLA5vkwxZmItTfSN78uaDmjt129sNtFYkNbAz87d0JeLVIzkgrk55x7Fnyzp7EthuJO2QYJM6c3YBXC790jhkzD9vhZIMDIC1n2BgMJHLxa2GTzjH+zPMPqOX8w7aCxDZmwlqAthhI87YdtjO4kdjGQJQWyfnPyqR5+w4nGNx42CyRcOYYD0G/GJw5vPkzz7fD9gbn0x9+/FFRI8ff3otfCwwkNkAZPEQpBwF7olWOglEwCkbByAMABfBM9xJNgRcAAAAASUVORK5CYII=","orcid":"","institution":"Shanghai Changhai Hospital","correspondingAuthor":true,"prefix":"","firstName":"Weidong","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2025-09-26 06:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7718491/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7718491/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92492569,"identity":"d880f9ec-7c7a-4449-990f-f646341beb94","added_by":"auto","created_at":"2025-09-30 09:50:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4368783,"visible":true,"origin":"","legend":"","description":"","filename":"Researchtrendsandhotspotsofalignmentinhightibialosteotomyabibliometricanalysis.docx","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/05f5efd47f8390a3203d8523.docx"},{"id":92491677,"identity":"98574140-bf1c-4680-b6b9-1df5025124f1","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"json","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6263,"visible":true,"origin":"","legend":"","description":"","filename":"0b4576201026494c848f8b0549fa3821.json","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/b645f7088c795bf80c2227e4.json"},{"id":92491678,"identity":"c17f026d-b775-4ff5-acb9-57299e58d4eb","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69868,"visible":true,"origin":"","legend":"","description":"","filename":"0b4576201026494c848f8b0549fa38211enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/562d65fafcd997efbfd35520.xml"},{"id":92493581,"identity":"87b756d0-494b-48dd-99a5-75de8e587e20","added_by":"auto","created_at":"2025-09-30 09:58:27","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1214720,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/1cb420db0457782aa45904f8.jpeg"},{"id":92491688,"identity":"b2fbf6cb-f542-4dff-b93f-f80a18542fa1","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1300028,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/388b91bfb9bb5d29ae1d07c0.jpeg"},{"id":92491689,"identity":"cc76dc92-f3b6-4281-ad3b-ee9762e9a857","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":3090496,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/1d854e25af765c6eac983cf2.jpeg"},{"id":92491686,"identity":"1dd136f1-ae4f-4b77-b939-66ec30b3606c","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":592740,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/fca516bb7684c1d5ec13727e.png"},{"id":92492567,"identity":"f520b9a1-ac1c-4ca7-9632-08b501cb04f0","added_by":"auto","created_at":"2025-09-30 09:50:27","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":620336,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/8fcdee994c43dc92bc1846ee.png"},{"id":92491687,"identity":"e939c954-bd15-45d3-b107-675a4a8fb523","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1677795,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/ab85055262f9dfffb8271bf1.png"},{"id":92491680,"identity":"e0161707-e310-4f2e-95da-58f958db4a12","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69974,"visible":true,"origin":"","legend":"","description":"","filename":"0b4576201026494c848f8b0549fa38211structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/e1525f270c2a411021afd219.xml"},{"id":92491684,"identity":"9c54e61f-b925-4d0d-a0d8-83412fa005e4","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73107,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/84fb9a3dae4b2813adc315f4.html"},{"id":92492566,"identity":"18fedb98-3c52-4d51-b4c1-8af41137411d","added_by":"auto","created_at":"2025-09-30 09:50:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":106689,"visible":true,"origin":"","legend":"\u003cp\u003eThe volumes, leading countries and the top affiliations by publication volume are summarized as follows.\u003cstrong\u003e(A) \u003c/strong\u003eAnnual number of publications;\u003cstrong\u003e(B)\u003c/strong\u003eTotal number of articles published in the top 10 countries;\u003cstrong\u003e(C)\u003c/strong\u003eNetwork map of collaborative relationships between countries;\u003cstrong\u003e(D)\u003c/strong\u003eTop 10 affiliations by publication volume\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/b776ea0dbd6fe002c3e1c4db.png"},{"id":92491675,"identity":"20044357-4d1d-44cb-b37a-f1ac63da346b","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":100965,"visible":true,"origin":"","legend":"\u003cp\u003eThe top authors by publication volume, production over time, visualization of the author collaboration network and cluster analysis are as follows\u003cstrong\u003e.(A) \u003c/strong\u003eTop 10 authors by publication volume;\u003cstrong\u003e(B)\u003c/strong\u003eTop 10 authors' production over time;\u003cstrong\u003e(C)\u003c/strong\u003eCoauthorship network visualization map of institutions;\u003cstrong\u003e(D)\u003c/strong\u003eTop 10 journals by publication volume\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/e532a8d0879e7ef6f31bf6fa.png"},{"id":92491681,"identity":"86d69c9b-0dbe-4ca5-9a96-af248f1a2050","added_by":"auto","created_at":"2025-09-30 09:42:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":235472,"visible":true,"origin":"","legend":"\u003cp\u003eAnalysis of keywords by temporal distribution, most relevant words, citation bursts, timeline view and clustering is as follows.\u003cstrong\u003e(A) \u003c/strong\u003eTemporal distribution analysis of keywords;\u003cstrong\u003e(B)\u003c/strong\u003eMost relevant words of keywords;\u003cstrong\u003e(C)\u003c/strong\u003eStrongest citation bursts analysis of keywords;\u003cstrong\u003e(D)\u003c/strong\u003eTimeline view of keywords;\u003cstrong\u003e(E)\u003c/strong\u003eClustering analysis of keywords\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/2abc418c5b96b666a3e0cdb1.png"},{"id":92715220,"identity":"0ae5e7c9-a494-4e14-bcc7-4c9c83ed84b6","added_by":"auto","created_at":"2025-10-03 12:17:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":883094,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7718491/v1/441ee42d-4aef-4edf-8757-596adca2d22c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Research trends and hotspots of alignment in high tibial osteotomy: a bibliometric analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKnee osteoarthritis (KOA) is a degenerative joint disease characterized by high incidence and disability rates\u003csup\u003e[1]\u003c/sup\u003e. The global prevalence of KOA among adults is approximately 16%, which increases significantly with age\u003csup\u003e[2]\u003c/sup\u003e. Approximately 30% of patients eventually progress to disability owing to symptom deterioration, and KOA constitutes nearly 80% of the global osteoarthritis burden\u003csup\u003e[3\u0026ndash;5]\u003c/sup\u003e, severely reducing patients' quality of life and imposing a heavy socioeconomic burden. Projections indicate that the number of people affected by KOA worldwide will increase by 74.9% from 2020\u0026ndash;2050\u003csup\u003e[6]\u003c/sup\u003e. Against the backdrop of a continuously aging population, the prevalence of KOA is expected to continue to rise, making its prevention and treatment a major challenge in the field of global public health\u003csup\u003e[7\u0026ndash;8]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCurrently, surgical interventions for KOA primarily include total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and high tibial osteotomy (HTO). While TKA and UKA demonstrate reliable outcomes in elderly patients, HTO is often considered the preferred joint-preserving procedure for younger, highly active patients with malalignment, as it preserves the native joint structure, corrects biomechanical alignment, and delays the progression of arthritis \u003csup\u003e[9\u0026ndash;10]\u003c/sup\u003e. Since its first description by Jackson and Waugh in 1961\u003csup\u003e[11]\u003c/sup\u003e, the technique has undergone standardized procedural refinements and continuous improvements in internal fixation devices. It is now widely used in young, active patients with varus KOA and has demonstrated favorable clinical outcomes. The mechanism of HTO involves shifting the weight-bearing axis to the lateral compartment of the knee, thereby reducing excessive load on the medial compartment\u003csup\u003e[12]\u003c/sup\u003e. This alleviates knee pain, improves functional mobility, slows osteoarthritis progression, and may delay or even prevent the need for knee arthroplasty\u003csup\u003e[13]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe key to successful HTO lies in accurate intraoperative achievement of the preoperative planning objectives. Among these factors, the target mechanical axis correction angle and the osteotomy opening width are the most critical factors influencing surgical success and long-term outcomes\u003csup\u003e[14\u0026ndash;16]\u003c/sup\u003e. Despite numerous technical advances, a certain degree of correction error remains common after HTO. Studies indicate that only approximately 70%-80% of cases achieve postoperative alignment within the target range postoperatively. Lee et al.\u003csup\u003e[17]\u003c/sup\u003e emphasized that periarticular soft tissue laxity significantly affects the accuracy of alignment correction, making it difficult to completely avoid deviations even with strict adherence to the preoperative plan. Mabrouk et al.\u003csup\u003e[18]\u003c/sup\u003e further highlighted that maintaining the posterior tibial slope and patellar height is crucial for stability during medial open-wedge HTO, as changes in these parameters can lead to under- or overcorrection. Additionally, Kili\u0026ccedil;li and Taşkiran\u003csup\u003e[19]\u003c/sup\u003e reported rare but serious cases of postoperative valgus deformity, suggesting that individual anatomical variations and soft tissue imbalance may be important contributors to correction inaccuracies.\u003c/p\u003e\u003cp\u003eBibliometrics is an interdisciplinary field that integrates mathematics, statistics, and information science, enabling multidimensional quantitative assessment of research dynamics in specific domains \u003csup\u003e[20]\u003c/sup\u003e. A standardized analytical framework has been established within medical research\u003csup\u003e[21]\u003c/sup\u003e. High tibial osteotomy, as a cornerstone of knee-preserving treatment, has garnered increasing clinical attention. Although the precision of lower limb alignment correction is widely recognized as a critical factor influencing HTO outcomes \u003csup\u003e[14\u0026ndash;16]\u003c/sup\u003e, a systematic bibliometric analysis is lacking. Existing reviews are largely confined to qualitative descriptions and lack quantitative evidence derived from scientometric visualization methods. Previous studies have often focused on isolated influencing factors, failing to systematically examine the principles of alignment change and its relationship with multidimensional outcome measures. Therefore, this study integrates bibliometric and visual analysis techniques to systematically outline development trends and emerging research hotspots in the field of lower limb alignment in HTO, with the aim of providing a reference for future investigations.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eAfter determining the search strategy and consulting MeSH terms from PubMed, a search was performed through the Web of Science Core Collection (WoSCC) database. The search strategy was as follows: (TS = (\"high tibial osteotomy\" OR \"hto\" OR \"tibial osteotomy\" OR \"open wedge osteotomy\" OR \"opening wedge osteotomy\" OR \"closed wedge osteotomy\" OR \"closing wedge osteotomy\") AND TS = (\"weight bearing line\" OR \"alignment\" OR \"mechanical axis\")). The search was completed on June 30, 2025, at 17:20:32 (GMT\u0026thinsp;+\u0026thinsp;0800, CST), yielding a total of 1,270 relevant articles from January 1981 to June 2025.\u003c/p\u003e\u003cp\u003eThe retrieved data were imported into Microsoft Excel 2019 for initial organization and collation. The Bibliometrix package in R 4.3.2 was then used for publication statistics and journal source analysis. VOSviewer 1.6.20 and Scimago Graphica 1.0.51 were used for national collaboration network analysis. CiteSpace 6.3. R1 was used for author and institutional collaboration analysis, as well as co-occurrence, clustering, and burst analysis of keywords.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePublication Volume and Temporal Trends\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1270 publications were retrieved, including 1210 research articles and 60 reviews. Research on alignment in HTO has demonstrated a continuous growth trend over the past decades. The surge in publication volume underscores the growing recognition of the importance of alignment in HTO research. Before 2001, research in this field was in its infancy, with fewer than 10 annual publications, indicating relatively limited academic attention (these publications were not included in Fig. 1A because of the small number). After 2018, exponential growth occurred, with an average annual growth rate of 22.1%, exceeding 100 publications by 2022. This surge reflects the widespread recognition of the importance of alignment issues in HTO and the increasingly strong link between research interest and clinical needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCountry/Region Distribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe top 10 countries in terms of publication numbers are shown in Fig. 1B. South Korea contributed the greatest number of publications (n=540, 42.5%), followed by the United States (n=479, 37.7%) and Japan (n=398, 31.3%). These three countries have made outstanding contributions to the number of publications in the field of HTO alignment.\u003c/p\u003e\n\u003cp\u003eResearch institutions from 48 countries and regions have published relevant results over time. These articles were published in 175 journals and involved 4318 authors. On the basis of information extracted from published articles, a world map was created to show collaborative research between different countries (Fig. 1C). Each circle represents a country, with size proportional to publication output; larger circles indicate greater contributions. The connecting lines between circles represent relationships between countries, with thicker lines indicating closer connections. As shown, the United States has the most extensive collaborative relationships with other countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Distribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1164 institutions contributed publications. As shown in Fig. 1D, the top three institutions by publication volume were Western University, Canada (77 articles); Assistance Publique-H\u0026ocirc;pitaux de Marseille, France (45 articles); and Seoul National University, South Korea (45 articles).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 4318 authors contributed to the relevant literature. As shown in Fig. 2A, the top three authors by publication volume were Lee YS (29 articles), Ollivier M (28 articles), and Birmingham TB (27 articles). A high-impact article published by Lee YS in 2022 evaluated the impact of different medial proximal tibial angles (MPTAs), representing joint line obliquity (JLO), on midterm radiographic and clinical outcomes after MOWHTO, suggesting that an MPTA exceeding 95.2 degrees is associated with poorer clinical outcomes\u003csup\u003e[22]\u003c/sup\u003e. As shown in Fig. 2B, the size of each node represents the annual output of individual authors, whereas the color depth indicates the total number of citations per year. Authors such as Lee YS, who demonstrate consistent or periodic high productivity, represent active leading forces in orthopedic research. Further observation reveals that some authors not only have stable paper output but also show an increasing trend in citations, suggesting high research quality and continuously expanding influence. The work of such authors may provide important references for future clinical practice and scientific research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of Productive Journals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFig. 2C shows a visualization map of productive journals. In the visual map, each node represents a journal, its size is proportional to the number of publications, node colors distinguish different research themes or clusters, and lines between nodes indicate collaboration or citation relationships between journals. More lines indicate higher citation frequency or stronger collaboration for papers published in that journal. Knee Surgery, Sports Traumatology, and Arthroscopy had the highest total citation frequency.As shown in Fig. 2D, the top 10 journals published 598 articles, accounting for approximately 47.08% of the total publications. Knee Surgery, Sports Traumatology, and Arthroscopy published the most articles (186), followed by Knee and the American Journal of Sports Medicine. This provides a reference for subsequent literature retrieval and journal influence evaluation in the field.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKeyword Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1428 keywords were identified. Fig. 3A shows the keyword co-occurrence network. Lines between nodes represent cooccurrences between different keywords. Each node represents a keyword. The circle size represents the frequency of occurrence. Different colors represent different clusters. Fig. 3B shows the top ten keywords were osteoarthritis, knee, alignment, high tibial osteotomy, follow-up, slope, arthritis, joint, long-term, and arthroplasty.\u003c/p\u003e\n\u003cp\u003eA keyword burst detection analysis was subsequently conducted. Keywords with the highest burst strength usually indicate emerging hotspots in the field during specific time periods. Keywords that burst earlier represent areas that have been focused on in previous research and may have established a certain research foundation, whereas keywords that burst recently indicate research directions with significantly increased attention at the current stage, potentially representing emerging research hotspots. As shown in Fig. 3C, the top five keywords by burst strength and their corresponding burst strengths were \u0026quot;long term\u0026quot; (17.77), \u0026quot;knee osteoarthritis\u0026quot; (11.03), \u0026quot;varus knee osteoarthritis\u0026quot; (10.91), \u0026quot;osteoarthritis\u0026quot; (9.18), and \u0026quot;conventional technique\u0026quot; (6.95). From a temporal perspective, the earliest bursting keywords were \u0026quot;arthritis\u0026quot; and \u0026quot;walking\u0026quot;. The most recent bursting keywords included \u0026quot;varus\u0026quot;, \u0026quot;overcorrection\u0026quot;, \u0026quot;limb alignment\u0026quot;, \u0026quot;joint line obliquity\u0026quot;, \u0026quot;knee osteoarthritis\u0026quot;, and \u0026quot;open-wedge high tibial osteotomy\u0026quot;.\u003c/p\u003e\n\u003cp\u003eFig. 3D presents a timeline view constructed on the basis of keyword co-occurrence analysis, which visualizes the distribution and evolution of keywords over time. The size of the nodes is proportional to the frequency of keyword occurrence, with larger nodes indicating that the term is more common in the overall research literature. Keywords located on the right side of the timeline with larger node sizes often represent currently focused research topics.\u003c/p\u003e\n\u003cp\u003eKeyword clustering can describe the knowledge structure and research topic distribution in a specific research field. Fig. 3E shows that keywords in the field of HTO alignment can be divided into seven clusters: \u0026quot;patellar height\u0026quot;, \u0026quot;high tibial osteotomy\u0026quot;, \u0026quot;gait\u0026quot;, \u0026quot;supramalleolar osteotomy\u0026quot;, \u0026quot;tibia vara\u0026quot;, \u0026quot;open-wedge high tibial osteotomy\u0026quot;, and \u0026quot;unicompartmental knee arthroplasty\u0026quot;.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study employed bibliometric and visual analysis to provide a comprehensive analysis of the current status and future trends in HTO alignment research. An analysis of the contributions of different countries, institutions, journals, and authors to research in this field identified emerging research directions and provided references for future research in this area.\u003c/p\u003e\n\u003cp\u003eIn recent years, the number of publications related to HTO alignment has increased significantly\u003csup\u003e[23]\u003c/sup\u003e, reflecting the growing importance attached to HTO as a key joint-preserving technology\u003csup\u003e[24,25]\u003c/sup\u003e. The increasing prevalence of KOA, driven by population aging, patients' expectations for greater functional recovery and delayed joint replacement, and improvements in HTO surgical techniques have collectively driven the vigorous development of this field. With continued attention to medium- and long-term efficacy and personalized precision treatment needs in HTO, research interest in this field is expected to remain high in the future.\u003c/p\u003e\n\u003cp\u003eNational analysis reveals that South Korea leads in publication volume, which may be attributed to the widespread adoption of knee-preservation concepts, its advantages in orthopedic technology development, and a robust academic output system. Although the United States trails slightly in publication numbers, its extensive international collaboration network (Figure 3) underscores its role as a global research hub. The rapid rise of China (ranking fourth) is also noteworthy. These findings suggest that research teams from different countries should actively pursue international collaboration, integrate complementary resources, and make concerted efforts to address the pivotal challenges in achieving precise mechanical axis alignment during HTO.\u003c/p\u003e\n\u003cp\u003eIn terms of institutions, Western University in Canada and Assistance Publique-Hôpitaux de Marseille in France are leading institutions in HTO alignment research. The continuous output of high-level results has laid a solid foundation for progress in this field. Researchers may consider collaborating with these institutions to deepen related research.\u003c/p\u003e\n\u003cp\u003eAuthor analysis indicates that Lee YS, as the most prolific author, has focused his research on postoperative radiographic evaluation, complications, and influencing factors of HTO, making important contributions to deepening the biomechanical understanding of HTO alignment correction and optimizing surgical plans. Monitoring the recent contributions of these core research teams and leading authors is an effective strategy for updating field developments.\u003c/p\u003e\n\u003cp\u003eJournal analysis revealed that Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) leads significantly in both publication volume and total citation frequency, fully demonstrating its authority as a top journal in sports medicine and arthroscopic surgery in the research field of HTO, a core joint-preserving technology. High-impact journals such as the American Journal of Sports Medicine (AJSM) and Knee constitute the main platforms for core knowledge dissemination and exchange in this field. Researchers should focus on these core publications when tracking cutting-edge progress and selecting target journals. The strong influence of KSSTA and AJSM also reflects that current research tends to be published in comprehensive journals focusing on sports medicine, arthroscopy, and knee surgery.\u003c/p\u003e\n\u003cp\u003eA detailed analysis of keyword co-occurrence results helps us grasp the hot topics in HTO alignment research. Cluster 1 is \"patellar height\". Open-wedge high tibial osteotomy may lead to decreased patellar height postoperatively\u003csup\u003e[26]\u003c/sup\u003e and cause anterior knee pain and limited activity\u003csup\u003e\u0026nbsp;[27]\u003c/sup\u003e. Excessive valgus correction can lead to poor patellar tracking during knee flexion\u003csup\u003e[28]\u003c/sup\u003e. Kim et al.\u003csup\u003e[29]\u003c/sup\u003e reported signs of patellofemoral joint cartilage deterioration during second-look arthroscopy approximately two years after open-wedge high tibial osteotomy. To address this issue, modified techniques to maintain patellar height have been proposed\u003csup\u003e[30]\u003c/sup\u003e. Horikawa et al.\u003csup\u003e[31]\u003c/sup\u003e reported that this technique can effectively maintain preoperative and postoperative patellar height. Cluster 2 is \"gait\". Three-dimensional gait analysis\u0026nbsp;confirmed\u0026nbsp;that HTO can not only effectively restore lower limb static alignment but also significantly reshape the dynamic gait biomechanical characteristics of patients with knee osteoarthritis\u003csup\u003e\u0026nbsp;[32]\u003c/sup\u003e. The main changes caused by open-wedge high tibial osteotomy are concentrated in the coronal plane, manifested as a significant reduction in the peak knee adduction moment and impulse\u003csup\u003e[33]\u003c/sup\u003e. Notably, postoperative alterations in gait kinetics and kinematics following HTO are three-dimensional. In addition to reduced knee adduction in the coronal plane, significant changes may also be observed in the sagittal and horizontal planes \u003csup\u003e[34]\u003c/sup\u003e. A deep understanding of these three-dimensional biomechanical changes is crucial for developing individualized, evidence-based postoperative rehabilitation programs. Future research needs to clarify whether significant changes in the sagittal and horizontal planes are the result of redistributed knee joint load or insufficient postoperative rehabilitation intervention \u003csup\u003e[35]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAccording to keyword burst analysis, long-term efficacy, individualized correction strategies and artificial intelligence-assisted planning and navigation may be research trends in the field of HTO alignment research. Achieving optimal alignment correction is the core goal of HTO, but other anatomical factors need to be considered comprehensively. Tibial factors account for only approximately 30% of varus knee deformities \u003csup\u003e[36]\u003c/sup\u003e. Correcting only the proximal tibia may lead to nonphysiological joint line obliquity (JLO) \u003csup\u003e[37]\u003c/sup\u003e. Studies have shown that a JLO exceeding 5° significantly increases shear stress on the tibial articular cartilage \u003csup\u003e[38]\u003c/sup\u003e, whereas a JLO exceeding 4° is significantly associated with a poorer Knee Society objective score and function score \u003csup\u003e[39]\u003c/sup\u003e. The medial proximal tibial angle (MPTA) is a key radiographic parameter for predicting postoperative JLO. Nakayama et al.\u0026nbsp;\u003csup\u003e[38]\u003c/sup\u003e proposed that an MPTA of 95° corresponds to a JLO of 5°. Oh et al.\u003csup\u003e[40]\u003c/sup\u003e reported\u0026nbsp;that patients with severe varus requiring large-angle correction are more likely to have\u0026nbsp;a\u0026nbsp;JLO \u0026gt;4°. Therefore, when preoperative planning predicts that\u0026nbsp;the\u0026nbsp;MPTA\u0026nbsp;exceeds 95° or that the JLO exceeds 4–5°, the applicability of HTO alone should be carefully evaluated, and alternative options such as biplanar osteotomy may be considered \u003csup\u003e[40]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOvercorrection (valgus overcorrection) is a complication that requires vigilance in HTO, especially when long-term efficacy is pursued, and its adverse effects are increasingly recognized \u003csup\u003e[41-46]\u003c/sup\u003e. Overcorrection not only affects appearance and patient satisfaction\u003csup\u003e[41]\u003c/sup\u003e but also significantly alters knee biomechanics, increases lateral compartment load, accelerates the progression of lateral osteoarthritis\u003csup\u003e[42]\u003c/sup\u003e, disrupts patellofemoral joint stability, increases the risk of patellar instability and dislocation, and accelerates patellofemoral joint cartilage and meniscal degeneration, worsening anterior knee pain\u003csup\u003e[43]\u003c/sup\u003e. Multiple studies have confirmed that overcorrection is significantly associated with accelerated patellar degeneration and poorer clinical outcomes postoperatively\u003csup\u003e[44-46]\u003c/sup\u003e. Furthermore, knees with excessive valgus may increase the difficulty of ligament balance during subsequent total knee arthroplasty (TKA)\u003csup\u003e[47]\u003c/sup\u003e. These risks highlight the importance of achieving precise alignment control while pursuing long-term efficacy of HTO to avoid the negative effects of overcorrection \u003csup\u003e[48]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eGiven that HTO is mainly suitable for relatively young, highly active patients with knee osteoarthritis\u003csup\u003e[49]\u003c/sup\u003e, its long-term efficacy is naturally a core concern for both doctors and patients. Although multiple studies have demonstrated that HTO effectively alleviates pain and improves knee function in the short to medium term, a subset of patients may eventually require TKA due to disease progression\u003csup\u003e[50-51]\u003c/sup\u003e. This raises an important clinical question: are the clinical outcomes of TKA performed after failed HTO inferior to those of primary TKA\u003csup\u003e[52]\u003c/sup\u003e. The existing evidence shows some heterogeneity. A meta-analysis suggested that, compared with primary TKA, TKA after failed HTO may be associated with a longer operation time, potential limitations in functional recovery, and greater risks of infection and revision\u003csup\u003e[53]\u003c/sup\u003e. However, some studies have reported no significant differences in standardized clinical scores or range of motion between the two groups of patients\u003csup\u003e[54]\u003c/sup\u003e. As the global burden of osteoarthritis continues to increase, the need for long-term studies to clarify the potential impact of HTO on subsequent TKA is becoming increasingly prominent. Therefore, evaluating the long-term efficacy of HTO and its potential impact on patients who eventually undergo TKA remains an important research direction\u0026nbsp;and is\u0026nbsp;directly related to patients' long-term quality of life and joint function.\u003c/p\u003e\n\u003cp\u003eDespite continuous improvements in surgical techniques, unexpected correction errors still occur after HTO\u003csup\u003e[17-19]\u003c/sup\u003e. Some studies report that only 70%–80% of alignments are within the target range postoperatively\u003csup\u003e[55,56]\u003c/sup\u003e. To improve accuracy, various personalized correction schemes based on patient-specific factors have been proposed. Jakob et al.\u003csup\u003e[57]\u003c/sup\u003e suggested\u0026nbsp;directly adjusting the target on the\u0026nbsp;basis of the\u0026nbsp;depth of medial compartment cartilage wear. Muller et al.\u003csup\u003e[58]\u003c/sup\u003e proposed a method for correction on the\u0026nbsp;basis of the\u0026nbsp;difference in cartilage softening between the medial and lateral compartments. Feucht et al.\u003csup\u003e[59]\u003c/sup\u003e also introduced a personalized scheme for adjusting the valgus angle on the\u0026nbsp;basis of the\u0026nbsp;patient's\u0026nbsp;Kellgren–Lawrence\u0026nbsp;grade of arthritis. In summary, in clinical practice, comprehensively\u0026nbsp;considering the\u0026nbsp;cartilage status, patient expected activity level, age, arthritis severity, and other key decision factors to achieve individualized precise correction\u0026nbsp;is recommended.\u003c/p\u003e\n\u003cp\u003eAdvancements in surgical technology have significantly improved the safety and precision of HTO. Intraoperative navigation technology and 3D-printed personalized osteotomy guides are representative technological innovations \u003csup\u003e[60-62]\u003c/sup\u003e. Numerous studies have confirmed the clinical advantages of 3D-printed individualized osteotomy guides. Research shows that these methods can simplify surgical steps, shorten the learning curve and operation time, and reduce the need for intraoperative fluoroscopy \u003csup\u003e[63-65]\u003c/sup\u003e, which is especially beneficial for handling complex deformities. Some meta-analyses also indicate\u003csup\u003e[66-68]\u0026nbsp;\u003c/sup\u003ethat navigation-assisted methods further improve correction accuracy by reducing outliers in alignment correction, providing real-time feedback, and better maintaining the posterior tibial slope, among other advantages. Mid-term follow-up also yields satisfactory clinical outcomes\u003csup\u003e[69]\u003c/sup\u003e. On this basis, we advocate combining AI preoperative planning with 3D-printed guides and intraoperative navigation to achieve real-time control of alignment, further enhancing the precision and success rate of HTO surgery.\u003c/p\u003e\n\u003cp\u003eThis study used bibliometric methods to systematically analyze the research status, main contributors, current research hotspots, and possible future research directions in the field of HTO alignment from 1981--2025. However, it inevitably has several limitations. First, during the literature retrieval process, the coverage of the literature in this study may have had a certain degree of incompleteness due to the selection range and precision of the search terms. Second, all bibliometric data included in this study came from the WoSCC database, ignoring other large databases. Some relevant literature contained in other databases may have been unavoidably omitted. However, the WoSCC is one of the most comprehensive and authoritative database platforms for obtaining global academic information and is considered the best database for bibliometric analysis. Furthermore, different databases have different characteristics, including different file output formats and citation calculation methods. Combining multiple databases may not be the best option. Finally, this study analyzed only English publications, potentially overlooking high-quality non-English articles. Moreover, the continuous updating of online databases may introduce bias into our bibliometric analysis results. These limitations will be addressed in future research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCurrent research in this field has focused primarily on patellar height alterations, gait analysis, and open-wedge high tibial osteotomy. The research landscape is dominated by South Korea, followed by the United States and Japan, with China rising rapidly. Enhancing international collaboration is crucial for driving more profound research developments in the future. On the basis of keyword burst analysis, clustering, and temporal evolution analysis, future research should pay more attention to long-term efficacy evaluation, the development and validation of personalized precision correction schemes on the basis of multiple factors, and the deep integration of artificial intelligence (AI) technology to improve surgical accuracy and efficiency. These findings provide important references for researchers to grasp the context of the field, focus on key scientific issues, and optimize clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to Xiaoyu Li, Weidong Xu for their invaluable guidance, support, and encouragement throughout this research. Their expertise and insights have greatly contributed to the success of this study. We would also like to thank the anonymous reviewers and the editorial board for their valuable comments and suggestions, which have signifificantly improved the quality of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: Shuo Zhang, Xiaoyu Li, Lin Shen\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Weidong Xu\u003c/p\u003e\n\u003cp\u003eThese authors contributed equally:Shuo Zhang, Xiaoyu Li, Lin Shen\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAuthor details\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Orthopedics, Shanghai Changhai Hospital, Shanghai, China\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of Orthopedics, Shanghai Changhai Hospital, Shanghai, China\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Outpatient, Shanghai Changzheng Hospital, Shanghai, China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*Correspondence:\u003c/strong\u003e Weidong Xu \u0026nbsp;e-mail:[email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019;393(10182):1745-1759.\u003c/li\u003e\n \u003cli\u003eCui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional incidence, incidence and risk factors for knee osteoarthritis in population-based studies. EClinicalMedicine. 2020;29-30:100587.\u003c/li\u003e\n \u003cli\u003eSafiri S, Kolahi AA, Smith E, et al. Global, regional and national burden of osteoarthritis 1990-2017: a systematic analysis of the Global Burden of Disease Study 2017. Ann Rheum Dis. 2020;79(6):819-828.\u003c/li\u003e\n \u003cli\u003eLiu Q, Wang S, Lin J, et al. The burden for knee osteoarthritis among Chinese elderly: estimates from a nationally representative study. Osteoarthritis Cartilage. 2018;26(12):1636-1642.\u003c/li\u003e\n \u003cli\u003eKatz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. JAMA. 2021;325(6):568-578.\u003c/li\u003e\n \u003cli\u003eGBD 2021 Osteoarthritis Collaborators. Global, regional, and national burden of osteoarthritis, 1990--2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(9):e508-e522.\u003c/li\u003e\n \u003cli\u003eSharma L. Osteoarthritis of the knee. N Engl J Med. 2021;384(1):51-59.\u003c/li\u003e\n \u003cli\u003eCross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-1330.\u003c/li\u003e\n \u003cli\u003eJackson JP, Waugh W. Tibial Osteotomy for Osteoarthritis of the Knee. Proc R Soc Med. 1960;53(10):888.\u003c/li\u003e\n \u003cli\u003eSong SJ, Yoon KH, Park CH. Patellofemoral Cartilage Degeneration After Closed- and Open-Wedge High-Tibial Osteotomy with Large Alignment Correction. Am J Sports Med. 2020;48(11):2718-2725.\u003c/li\u003e\n \u003cli\u003eDal Fabbro G, Grassi A, Agostinone P, et al. High survivorship rate and good clinical outcomes after high tibial osteotomy in patients with radiological advanced medial knee osteoarthritis: a systematic review. Arch Orthop Trauma Surg. 2024;144(9):3977-3988.\u003c/li\u003e\n \u003cli\u003eAgneskirchner JD, Hurschler C, Wrann CD, et al. The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy. 2007;23(8):852-861.\u003c/li\u003e\n \u003cli\u003eBode L, Eberbach H, Brenner AS, et al. 10-Year Survival Rates After High Tibial Osteotomy Using Angular Stable Internal Plate Fixation: Case Series With Subgroup Analysis of Outcomes After Combined Autologous Chondrocyte Implantation and High Tibial Osteotomy. Orthop J Sports Med. 2022;10(2):23259671221078003.\u003c/li\u003e\n \u003cli\u003eEngel GM, Lippert FG. Valgus tibial osteotomy: avoiding pitfalls. Clin Orthop Relat Res. 1981;(160):137-143.\u003c/li\u003e\n \u003cli\u003eKang Y, Kim J, Sim JA, et al. Stress Effect in the Knee Joint Based on the Fibular Osteotomy Level and Varus Deformity: A Finite Element Analysis Study. Bioengineering. 2023;10(9):1003.\u003c/li\u003e\n \u003cli\u003eLind-Hansen TB, Lind MC, Nielsen PT, et al. Open-Wedge High Tibial Osteotomy: RCT 2 Years RSA Follow-Up. J Knee Surg. 2016;29(8):664-672.\u003c/li\u003e\n \u003cli\u003eLee DH, Park SC, Park HJ, et al. Effect of soft tissue laxity of the knee joint on limb alignment correction in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3704-3712.\u003c/li\u003e\n \u003cli\u003eMabrouk A, An JS, Fernandes LR, et al. Maintaining Posterior Tibial Slope and Patellar Height During Medial Opening Wedge High Tibial Osteotomy. Orthop J Sports Med. 2023;11(12):23259671231213595.\u003c/li\u003e\n \u003cli\u003eKili\u0026ccedil;li B, Taşkiran E. A Rare Complication: Severe Valgus Deformity After Open-Wedge High Tibial Osteotomy. J Orthop Case Rep. 2024;14(4):84-89.\u003c/li\u003e\n \u003cli\u003eBornmann L, Leydesdorff L. Scientometrics in a changing research landscape: bibliometrics has become an integral part of research quality evaluation and has been changing the practice of research. EMBO Rep. 2014;15(12):1228-1232.\u003c/li\u003e\n \u003cli\u003eChiu WT, Ho YS. Bibliometric analysis of tsunami research. Scientometrics. 2007;73(1):3-17.\u003c/li\u003e\n \u003cli\u003eKim JS, Lim JK, Choi HG, et al. Excessively Increased Joint-Line Obliquity After Medial Opening-Wedge High Tibial Osteotomy Is Associated With Inferior Radiologic and Clinical Outcomes: What Is Permissible Joint-Line Obliquity. Arthroscopy. 2022;38(6):1904-1915.\u003c/li\u003e\n \u003cli\u003eMa XL, Hu YC, Wang KZ, et al; Chinese Hospital Association Clinical Medical Technology Application Committee. Chinese clinical practice guidelines in treating knee osteoarthritis by periarticular knee osteotomy. Orthop Surg. 2022;14(5):789-806.\u003c/li\u003e\n \u003cli\u003eHuang Y, Lobenhoffer P, Jiang XY. Development of knee-preserving osteotomy in China. Sci Bull. 2023;68(2):125-128.\u003c/li\u003e\n \u003cli\u003eHoorntje A, Witjes S, Kuijer P, et al. High rates of return to sports activities and work after osteotomies around the knee: a systematic review and meta-analysis. Sports Med. 2017;47(11):2219-2244.\u003c/li\u003e\n \u003cli\u003eBin SI, Kim HJ, Ahn HS, Rim DS, Lee DH. Changes in patellar height after opening wedge and closing wedge high tibial osteotomy: a meta-analysis. Arthroscopy. 2016;32(11):2393-2400.\u003c/li\u003e\n \u003cli\u003eStoffel K, Willers C, Korshid O, Kuster M. Patellofemoral contact pressure following high tibial osteotomy: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. 2007;15(9):1094-1100.\u003c/li\u003e\n \u003cli\u003eLee SS, So SY, Jung EY, Kim HJ, Lee BH, Wang JH. Predictive factors for patellofemoral degenerative progression after opening-wedge high tibial osteotomy. Arthroscopy. 2019;35(6):1703-1710.\u003c/li\u003e\n \u003cli\u003eKim KI, Kim DK, Song SJ, Lee SH, Bae DK. Medial open-wedge high tibial osteotomy may adversely affect the patellofemoral joint. Arthroscopy. 2017;33(4):811-816.\u003c/li\u003e\n \u003cli\u003eGaasbeek R, Sonneveld H, Van Heerwaarden R, Jacobs W, Wymenga A. Distal tuberosity osteotomy in open wedge high tibial osteotomy can prevent patella infera: a new technique. Knee. 2004;11(6):457-461.\u003c/li\u003e\n \u003cli\u003eHorikawa T, Kubota K, Hara S, Akasaki Y. Distal tuberosity osteotomy in open-wedge high tibial osteotomy does not exacerbate patellofemoral osteoarthritis on arthroscopic evaluation. Knee Surg Sports Traumatol Arthrosc. 2020;28(6):1750-1756.\u003c/li\u003e\n \u003cli\u003eSenior D. Qualisys medical AB: Qualisys Track Manager user manual. Gothenburg: NRC Publications Archive (NPArC); 2004.\u003c/li\u003e\n \u003cli\u003eGetgood A, Collins B, Slynarski K, et al. Short-term safety and efficacy of a novel high tibial osteotomy system: a case controlled study. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):260-269.\u003c/li\u003e\n \u003cli\u003eLee DW, Han HS, Ro DH. Comparative gait analysis: Similar coronal but different sagittal effects between closing-wedge and opening-wedge high tibial osteotomies. Clin Biomech. 2024;114:106238.\u003c/li\u003e\n \u003cli\u003eda Silva HGPV, Zorzi AR, da Silva HPV, et al. Gait analysis in short-term follow-up of medial opening wedge high tibial osteotomy. Eur J Orthop Surg Traumatol. 2028;28(5):939-946.\u003c/li\u003e\n \u003cli\u003eHofmann S, Lobenhoffer P, Staubli A, Van Heerwaarden R. Osteotomies of the knee joint in patients with monocompartmental arthritis. Orthopade. 2009;38(8):755-769.\u003c/li\u003e\n \u003cli\u003eTakeuchi R, Ishikawa H, Aratake M, et al. Medial opening wedge high tibial osteotomy with early full weight bearing. Arthroscopy. 2009;25(1):46-53.\u003c/li\u003e\n \u003cli\u003eNakayama H, Schr\u0026ouml;ter S, Yamamoto C, et al. Large correction in opening wedge high tibial osteotomy with resultant joint-line obliquity induces excessive shear stress on the articular cartilage. Knee Surg Sports Traumatol Arthrosc. 2018;26(6):1873-1878.\u003c/li\u003e\n \u003cli\u003eSong JH, Bin SI, Kim JM, Lee BS. What is the acceptable limit of joint-line obliquity after medial open wedge high tibial osteotomy? Analysis on the basis of the midterm results. Am J Sports Med. 2020;48(12):3028-3035.\u003c/li\u003e\n \u003cli\u003eOh KJ, Ko YB, Bae JH, Yoon ST, Kim JG. Analysis of knee joint line obliquity after high tibial osteotomy. J Knee Surg. 2016;29(8):649-657.\u003c/li\u003e\n \u003cli\u003eMurray 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):e21.00141.\u003c/li\u003e\n \u003cli\u003eYoon TH, Choi CH, Kim SJ, et al. Effect of Medial Open-Wedge High Tibial Osteotomy on the Patellofemoral Joint According to Postoperative Realignment. Am J Sports Med. 2019;47(8):1863-1873.\u003c/li\u003e\n \u003cli\u003eYin Y, Li S, Zhang R, et al. What is the relationship between the \u0026ldquo;Fujisawa point\u0026rdquo; and postoperative knee valgus angle? A theoretical, computer-based study. Knee. 2020;27(1):183-191.\u003c/li\u003e\n \u003cli\u003eLee SS, So SY, Jung EY, et al. Predictive Factors for Patellofemoral Degenerative Progression After Opening-Wedge High Tibial Osteotomy. Arthroscopy. 2019;35(6):1703-1710.\u003c/li\u003e\n \u003cli\u003eSong SJ, Bae DK, Kim KI, et al. Conversion Total Knee Arthroplasty after Failed High Tibial Osteotomy. Knee Surg Relat Res. 2016;28(2):89-98.\u003c/li\u003e\n \u003cli\u003eMurray 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):e21.00141.\u003c/li\u003e\n \u003cli\u003eKim KI, Lee SH, Kim JH. The presence or absence of cartilage regeneration following medial open-wing high-tibial osteotomy does not predict long-term outcomes. Arthroscopy. 2025;S0749-8063(25)00493-1.\u003c/li\u003e\n \u003cli\u003eAyet CAB, Mancino F, Lim YP, et al. Satisfactory 10-year survivorship of medial opening wedge high tibial osteotomy for isolated medial compartment osteoarthritis and varus alignment: An analysis from a high-volume institution. Knee Surg Sports Traumatol Arthrosc. 2025;33(5):1804-1814.\u003c/li\u003e\n \u003cli\u003eSharma L. Osteoarthritis of the Knee. N Engl J Med. 2021;384(1):51-59.\u003c/li\u003e\n \u003cli\u003eSchr\u0026ouml;ter S, Mueller J, van Heerwaarden R, et al. Return to work and clinical outcome after open wedge HTO. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):213-219.\u003c/li\u003e\n \u003cli\u003eWhatling GM, Biggs PR, Elson DW, et al. High tibial osteotomy results in improved frontal plane knee moments, gait patterns and patient-reported outcomes. Knee Surg Sports Traumatol Arthrosc. 2020;28(9):2872-2882.\u003c/li\u003e\n \u003cli\u003eRobertsson O, W-Dahl A. The risk of revision after TKA is affected by previous HTO or UKA. Clin Orthop Relat Res. 2015;473(1):90-93.\u003c/li\u003e\n \u003cli\u003eShen G, Shen D, Fang Y, et al. Clinical Outcomes of Revision Total Knee Arthroplasty after High Tibial Osteotomy and Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-Analysis. Orthop Surg. 2022;14(8):1549-1557.\u003c/li\u003e\n \u003cli\u003eBae DK, Song SJ, Park CH, Liang H, Bae JK. Comparison of midterm results between conversion total knee arthroplasties following closed wedge high tibial osteotomy and primary total knee arthroplasties: A matched pair study including patellar symptoms and position. J Orthop Sci. 2017;22(3):495-500.\u003c/li\u003e\n \u003cli\u003eGebhard F, Krettek C, H\u0026uuml;fner T, et al. Reliability of computer-assisted surgery as an intraoperative ruler in navigated high tibial osteotomy. Arch Orthop Trauma Surg. 2011;131(3):297-302.\u003c/li\u003e\n \u003cli\u003eWang G, Zheng G, Keppler P, et al. Implementation, accuracy evaluation, and preliminary clinical trial of a CT-free navigation system for high tibial opening wedge osteotomy. Comput Aided Surg. 2005;10(2):73-86.\u003c/li\u003e\n \u003cli\u003eJakob RP, Jacobi M. Closing wedge osteotomy of the tibial head in treatment of single compartment arthrosis. Orthopade. 2004;33(2):143-152.\u003c/li\u003e\n \u003cli\u003eM\u0026uuml;ller M, Strecker W. Arthroscopy prior to osteotomy around the knee? Arch Orthop Trauma Surg. 2008;128(11):1217-1221.\u003c/li\u003e\n \u003cli\u003eFeucht 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):2273-2280.\u003c/li\u003e\n \u003cli\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/li\u003e\n \u003cli\u003eAman ZS, DePhillipo NN, Peebles LA, et al. Improved Accuracy of Coronal Alignment Can Be Attained Using 3D-Printed Patient-Specific Instrumentation for Knee Osteotomies: A Systematic Review of Level III and IV Studies. Arthroscopy. 2022;38(9):2741-2758.\u003c/li\u003e\n \u003cli\u003eKyung BS, Kim JG, Jang KM, et al. Are navigation systems accurate enough to predict the correction angle during high tibial osteotomy? Comparison of navigation systems with 3-dimensional computed tomography and standing radiographs. Am J Sports Med. 2013;41(10):2368-2374.\u003c/li\u003e\n \u003cli\u003eVan Genechten W, Van Tilborg W, Van den Bempt M, et al. Feasibility and 3D Planning of a Novel Patient-Specific Instrumentation Technique in Medial Opening-Wedge High Tibial Osteotomy. J Knee Surg. 2021;34(14):1560-1569.\u003c/li\u003e\n \u003cli\u003eJacquet C, Sharma A, Fabre M, et al. Patient-specific high-tibial osteotomy\u0026rsquo;s \u0026ldquo;cutting-guides\u0026rdquo; decrease operating time and the number of fluoroscopic images taken after a Brief Learning Curve. Knee Surg Sports Traumatol Arthrosc. 2020;28(9):2854-2862.\u003c/li\u003e\n \u003cli\u003eDonnez M, Ollivier M, Munier M, et al. Are three-dimensional patient-specific cutting guides for open wedge high tibial osteotomy accurate? An in vitro study. J Orthop Surg Res. 2018;13(1):171.\u003c/li\u003e\n \u003cli\u003eKim HJ, Yoon JR, Choi GW, et al. Imageless Navigation Versus Conventional Open Wedge High Tibial Osteotomy: A Meta-Analysis of Comparative Studies. Knee Surg Relat Res. 2016;28(1):16-26.\u003c/li\u003e\n \u003cli\u003eYan J, Musahl V, Kay J, et al. Outcome reporting following navigated high tibial osteotomy of the knee: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24(11):3529-3555.\u003c/li\u003e\n \u003cli\u003eNha KW, Shin YS, Kwon HM, et al. Navigated versus Conventional Technique in High Tibial Osteotomy: A Meta-Analysis Focusing on Weight Bearing Effect. Knee Surg Relat Res. 2019;31(2):81-102.\u003c/li\u003e\n \u003cli\u003eHasegawa M, Naito Y, Tone S, et al. Correction to: High rates of outliers in computer-assisted high tibial osteotomy with excellent mid-term outcomes. Knee Surg Sports Traumatol Arthrosc. 2023;31(2):406.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bibliometric analysis, High tibial osteotomy, Alignment, Research trends, Research hotspots","lastPublishedDoi":"10.21203/rs.3.rs-7718491/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7718491/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective \u003c/strong\u003eTo analyze the literature on lower limb alignment in high tibial osteotomy, highlighting development trends, the current research status, and potential emerging frontiers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eA comprehensive search was conducted in the Web of Science Core Collection for literature on lower limb alignment in high tibial osteotomy, covering the period from January 1, 1981, to June 30, 2025. Bibliometric tools, including VOSviewer, R Bibliometrix, and CiteSpace, were employed to assess the research landscape and evaluate core authors, journals, and contributing countries. Keyword co-occurrence and cluster analyses were performed to identify global research trends and hotspots.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eA total of 1270 articles published between January 1981 and June 2025 were included, showing a gradual increase in annual publications. Knee Surgery Sports Traumatology Arthroscopy presented the highest publication volume and influence. Lee YS was the most prolific author. Western University in Canada was the most productive institution. South Korea contributed the most publications, followed by the United States, which demonstrated the most extensive international collaboration network. Current research focuses primarily on patellar height changes, gait analysis, and open-wedge high tibial osteotomy. Future research trends are expected to concentrate on long-term outcomes, individualized strategies, and artificial intelligence-assisted planning and navigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eIn recent years, significant advancements have been achieved in research on alignment in HTO. With increasing patient expectations regarding long-term surgical outcomes, there is a growing imperative for systematic long-term follow-up and evaluation of postoperative alignment changes. The optimization of individualized treatment strategies has emerged as a pivotal direction for enhancing surgical efficacy. The integration of artificial intelligence into surgical planning and navigation holds substantial promise for improving operative accuracy, patient satisfaction, and overall success rates. Collectively, these developments are expected to catalyze higher-quality research and yield superior clinical solutions for HTO.\u003c/p\u003e","manuscriptTitle":"Research trends and hotspots of alignment in high tibial osteotomy: a bibliometric analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 09:42:22","doi":"10.21203/rs.3.rs-7718491/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4aa931f8-b9cb-405e-8ded-e8a32361370d","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-03T12:08:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-30 09:42:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7718491","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7718491","identity":"rs-7718491","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}