Impact of Mechanical Axis Position and Coronal Plane Alignment Phenotypes on Clinical Outcomes in Medial Opening Wedge High Tibial Osteotomy

Impact of Mechanical Axis Position and Coronal Plane Alignment Phenotypes on Clinical Outcomes in Medial Opening Wedge High Tibial Osteotomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Mechanical Axis Position and Coronal Plane Alignment Phenotypes on Clinical Outcomes in Medial Opening Wedge High Tibial Osteotomy Ahmetcan Erdem, Vahdet Uçan, Gökhan Lebe, Muhammet Ali Geçkalan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7142721/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Introduction: Medial opening wedge high tibial osteotomy (MOWHTO) is a widely used surgical technique for treating varus-aligned medial compartment knee osteoarthritis. While traditional strategies emphasize lateralizing the mechanical axis toward the Fujisawa point, recent biomechanical insights suggest that excessive valgus correction (>2°) may increase stress on the lateral compartment without conferring additional clinical benefit. Moreover, restoring a horizontal joint line is essential to optimize load distribution and improve knee function. The Coronal Plane Alignment of the Knee (CPAK) classification provides a phenotype-based framework that incorporates both mechanical axis deviation and joint line obliquity (JLO), though its application in MOWHTO remains underexplored. Material and Methods: A retrospective study was conducted on 147 knees in 123 patients who underwent MOWHTO with a minimum follow-up of 24 months. Radiographic parameters evaluated included mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA), arithmetic hip-knee-ankle angle (aHKA), and JLO. Patients were categorized into five groups based on postoperative weight-bearing line (WBL) position across the tibial plateau. CPAK phenotypes were recorded pre- and postoperatively. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) knee score. Results: CPAK type I (varus alignment with distal apex) was the predominant preoperative phenotype (82.3%). Postoperatively, a notable proportion of knees transitioned to CPAK types V (24.5%) and VI (17.7%), both associated with significantly higher HSS scores (p < 0.001). The mean aHKA improved from −7.35° to +1.59° (p < 0.001), and JLO corrected from 172.4° to 180.8° (p 0.05). Clinical outcomes were most favourable in patients with postoperative WBL positions between 50% and 60%, comparable to outcomes achieved at the Fujisawa point. Conclusion: Successful outcomes in MOWHTO depend not only on lateralization of the mechanical axis but also on restoring joint line orientation. This study is among the first to apply the CPAK classification to MOWHTO and demonstrates its potential for guiding phenotype-based, individualized correction strategies. Targeting a WBL position between 50% and 60%, along with horizontal joint line restoration, appears to optimize clinical results. Level of evidence: Level III (retrospective comparative study) High tibial osteotomy mechanical axis alignment coronal plane alignment CPAK classification joint line obliquity knee osteoarthritis clinical outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Medial opening wedge high tibial osteotomy (MOWHTO) is a well-established procedure for the treatment of medial compartment knee osteoarthritis (OA) with varus malalignment. By laterally shifting the mechanical load-bearing axis, MOWHTO unloads the degenerated medial compartment and alleviates pain, thereby improving function [ 1 ]. Achieving optimal postoperative lower limb alignment is considered crucial for favourable clinical outcomes; however, there is still no consensus on the ideal correction target [ 2 – 5 ]. Recent biomechanical studies have raised concerns that excessive valgus (> 2°) may increase stress on the lateral compartment without providing additional clinical benefit [ 6 – 9 ]. The concept of constitutional alignment refers to the native coronal alignment of the limb prior to the onset of osteoarthritis. In healthy, pre-arthritic knees, the joint line is typically horizontal. However, disease progression disrupts this orientation, often leading to altered joint line obliquity (JLO). This change has increased interest in restoring physiological joint line orientation during corrective procedures. In this context, the Coronal Plane Alignment of the Knee (CPAK) classification system, introduced by MacDessi et al., provides a structured framework that categorizes knee alignment into nine phenotypes based on mechanical axis deviation and JLO. While CPAK was initially developed for total knee arthroplasty (TKA), its application to osteotomy represents a novel approach that may help tailor alignment strategies and refine surgical planning [ 10 ]. In MOWHTO, surgical objectives extend beyond lateralization of the mechanical axis; restoring a more horizontal joint line is also essential to optimize knee biomechanics. Importantly, not all varus knees share the same phenotype; accurate interpretation of joint line obliquity (JLO), particularly the direction of its apex, is essential for precise surgical planning. For instance, CPAK Types I and IV—characterized by varus alignment and distal or neutral JLO—are commonly associated with medial compartment OA and are typical targets for osteotomy. This heterogeneity should be considered in surgical planning. Postoperatively, conversion to valgus phenotypes such as Type VI (with neutral JLO) may reflect more favorable joint alignment and load distribution. Although correction targets such as the Fujisawa point and mild valgus alignment have been studied in MOWHTO, few investigations have systematically examined alignment using the CPAK classification, which integrates both mechanical axis and JLO [ 11 – 13 ]. The potential utility of this system in improving individualized correction and predicting outcomes remains underexplored. The aims of this retrospective study were: (1) to investigate the impact of different postoperative alignment targets—including deviations from the Fujisawa point—on clinical outcomes following MOWHTO, (2) to analyze the distribution of CPAK phenotypes before and after surgery, and (3) to assess the relationship between CPAK phenotype, mechanical axis deviation, JLO, and clinical outcomes. To our knowledge, this is one of the first studies to apply the CPAK classification in the setting of MOWHTO, and it may provide new insights for phenotype-based, personalized alignment strategies. Materials and Methods This retrospective cohort study included 147 knees from 123 patients who underwent MOWHTO between 2017 and 2022 at a single institution, with a minimum clinical follow-up of 24 months. Ethical approval was obtained from the institutional review board of …. The mean age of patients was 47.0 ± 10.3 years, with 45 males (36.5%) and 78 females (63.5%). Surgeries involved the right knee in 66 cases (44.9%) and the left knee in 81 cases (55.1%). Twelve patients had staged bilateral procedures, and eight underwent simultaneous anterior cruciate ligament reconstruction. The mean follow-up duration was 28.7 ± 7.9 months. Osteoarthritis severity was graded using the Kellgren–Lawrence system, with the majority classified as Stage 2 (n = 66) or Stage 3 (n = 69), and only 12 knees at Stage 4. Patients included in the study had provided written informed consent and presented primarily with anteromedial knee pain and medial compartment osteoarthritis. They were aged between 30 and 60 years, had full knee range of motion with flexion contracture less than 10°, and intact lateral compartment cartilage and menisci. Exclusion criteria were BMI over 35 kg/m², multicompartmental osteoarthritis, non-degenerative joint disease, prior major lower limb surgery, or complete loss of medial joint space on standing radiographs. All procedures were performed under spinal anesthesia. Initial diagnostic arthroscopy addressed intra-articular pathology, followed by a biplanar MOWHTO. The superficial medial collateral ligament was released subperiosteally. Two K-wires were inserted about 4 cm distal to the joint line toward the fibular head to guide the osteotomy. A horizontal cut was made above the patellar tendon insertion, with an ascending cut angled approximately 110° to the horizontal. A lateral cortical hinge of roughly 1 cm was preserved. The osteotomy gap was opened gradually with a laminar spreader, creating a trapezoidal defect wider posteromedially. Fixation was achieved using a TomoFix locking plate system. Patients received intravenous cefuroxime 30 minutes before surgery and low-molecular-weight heparin (enoxaparin) for thromboprophylaxis over 10 days postoperatively. Rehabilitation started on day one with isometric and straight-leg-raising exercises. Toe-touch weight-bearing was permitted immediately, partial weight-bearing began at 3 weeks, and full weight-bearing was allowed at 6 weeks after radiographic confirmation of healing. Radiographic evaluation utilized standardized, full-length, weight-bearing anteroposterior radiographs taken preoperatively and at final follow-up. Parameters measured included the mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA), arithmetic hip-knee-ankle angle (aHKA, calculated as MPTA minus mLDFA), and joint line obliquity (JLO, calculated as MPTA plus mLDFA). The weight-bearing line (WBL) position was expressed as a percentage of the tibial plateau width from medial (0%) to lateral (100%). Postoperative alignment was categorized into five groups: Group 1 with WBL less than 50% indicating undercorrection; Group 2 with WBL between 50 and 55% considered neutral; Group 3 with WBL 55–60% representing mild valgus; Group 4 with WBL 60–65% corresponding to the Fujisawa point; and Group 5 with WBL greater than 65%, indicating overcorrection. Knee phenotypes were classified using the Coronal Plane Alignment of the Knee (CPAK) system, which incorporates mechanical axis deviation and joint line obliquity. Alignment was categorized based on aHKA as varus ( ≤ − 2°), neutral (between − 2° and 2°), or valgus (≥ 2°). Joint line obliquity was classified as apex distal (JLO ≤ 177°), apex neutral (177°–183°), or apex proximal (≥ 183°). JLCA was graded as normal (≤ 2°), increased (2°–3°), or severely increased (≥ 4°), with a change of 2° or more considered clinically significant. The MPTA was classified as normal (85°–90°), increased (90°–95°), or severely increased (> 95°). Functional outcomes were evaluated using the Hospital for Special Surgery (HSS) knee score at baseline and final follow-up, with scores categorized as fair (70–80), good (81–85), very good (86–90), or excellent (> 90). Statistical Analysis Statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 29.0.2. Descriptive statistics summarized patient characteristics and outcomes. Group comparisons used one-way ANOVA for normally distributed variables and the Kruskal–Wallis test for non-parametric data, with post hoc testing as needed. Statistical significance was set at p < 0.05. Results Preoperative analysis showed no statistically significant differences among groups regarding age, sex distribution, side of surgery, alignment parameters (mFTA, mMPTA, mLDFA, JLCA), or functional outcome scores (HSS), with all p-values > 0.05. Both mFTA and mMPTA showed significant pre- to postoperative changes across groups (Kruskal-Wallis test, p < 0.001). The aHKA improved from − 7.35° (varus) to + 1.59° (slight valgus), representing a mean correction of + 8.74° (t = 21.621, p < 0.001). Joint line orientation (JLO) was corrected from 172.4° to 180.8° (p 0.05), suggesting no significant femoral side correction. The joint line convergence angle (JLCA) also showed a non-significant change of + 0.16° (t = 1.506, p > 0.05), indicating preserved joint space alignment. The Hospital for Special Surgery (HSS) score improved significantly by 50.12 points (t = 78.002, p < 0.001), reflecting substantial clinical improvement in pain relief and knee function (Table 1 ). Functional outcomes across groups showed significant postoperative HSS score improvements (p < 0.001) (Table 2 ). Notably, groups 1 and 5 recorded the lowest HSS scores (84.4 ± 4.9 and 82.2 ± 4.3, respectively), suggesting that both undercorrection and overcorrection adversely affect clinical outcomes (p = 0.002). Group 5 exhibited the highest mMPTA (94.0° ± 4.2°), consistent with overcorrection and joint line obliquity. Patients with severely increased JLCA (≥ 4°) tended to have lower HSS scores, with only 6.9% achieving excellent results (Tables 3 – 5 , Figs. 1 – 4 ). Table 1 Comparison of preoperative and postoperative measurements Measurement Preoperative Mean ± SD Postoperative Mean ± SD Mean Difference ± SD t P mFTA 187.76 ± 3.24 178.45 ± 3.97 -9.31 ± 4.45 25.337 < 0.001 MPTA 82.56 ± 3.11 91.05 ± 4.32 + 8.49 ± 4.69 21.936 0.05 aHKA -7.35 ± 3.50 1.59 ± 4.62 + 8.74 ± 4.90 21.621 < 0.001 JLO 172.40 ± 4.46 180.80 ± 5.39 + 8.39 ± 5.56 18.314 0.05 HSS 35.73 ± 7.15 85.85 ± 4.57 + 50.12 ± 7.79 78.002 < 0.001 mFTA: Mechanical femorotibial angle, MPTA: Medial proximal tibial angle, mLDFA: Mechanical lateral distal femoral angle, aHKA: Arithmetic hip knee angle, JLO: Joint line obliquity, JLCA: Joint line convergence angle HSS: Hospital for special surgery Table 2 Postop. clinical scores and radiologic characteristics according to groups Postop. Group 1 Group 2 Group 3 Group 4 Group 5 No of Patients 42 (28.6%) 44 (29.9%) 21 (14.3%) 15 (10.2%) 25 (17.0%) HSS 84.4 ± 4.9 87.9 ± 3.1 87.1 ± 2.8 88.1 ± 4.4 82.2 ± 4.3 Δ HSS -5.661 -5.802 -4.029 -3.441 -4.414 mFTA 181.05 ± 4.5 178.1 ± 2.7 178.5 ± 1.9 177.8 ± 2.2 174.8 ± 3.9 mMPTA 88.6 ± 3.4 91.2 ± 3.9 90.8 ± 4.2 92.6 ± 4.3 94.0 ± 4.2 mLDFA 90.26 ± 3.00 89.64 ± 2.45 89.57 ± 3.30 88.80 ± 1.66 89.04 ± 2.01 aHKA -1.6 ± 4.1 1.7 ± 3.8 2.0 ± 3.7 3.8 ± 2.0 5.0 ± 4.3 JLCA 1.69 ± 1.18 2.02 ± 1.62 2.19 ± 1.01 1.47 ± 1.02 2.32 ± 1.71 JLO 4.38 ± 1.9 4.73 ± 2.4 3.67 ± 1.6 4.93 ± 2.6 5.04 ± 1.7 Values are shown as n (%) or mean ± standart deviations, Group 1 (WBL 65%). HSS: Hospital for Special Surgery. The Δ HSS (postop - preop) was consistently negative across all groups, indicating substantial improvement postoperatively. Table 3 shows Clinical scores (HSS) according to groups HSS score Group 1 Group 2 Group 3 Group 4 Group 5 90 point 1 3 1 3 0 Table 4 JLCA groups and postop. HSS scores (P > 0.005) HSS score Group 1 ( 4) 90 point 5 (7.2%) 3 (4.3%) 0 (0.0%) Table 5 MPTA groups and postop.HSS scores (P > 0.005) HSS Score MPTA 95 90 point 3 (37.5%) 4 (50.0%) 1 (12.5%) Preoperative CPAK Type 1 was most prevalent (121/147 knees, 82.3%), characterized by varus alignment with apex distal joint lines, indicating tibial deformity and joint line obliquity. CPAK Type 4 accounted for 18 knees (17.7%) with varus alignment and apex neutral joint lines, primarily reflecting bony deformity without joint line tilt. Postoperatively, many Type 1 patients transitioned to CPAK Type 5 (neutral mechanical axis, apex neutral joint line; n = 36, 24.5%) or Type 6 (valgus alignment, apex neutral joint line; n = 26, 17.7%) (Table 6 ). Clinical outcomes improved significantly across all CPAK groups postoperatively (Wilcoxon signed ranks test, p = 0.001). Lower HSS scores were associated with both undercorrection (Group 1, 33.3%) and overcorrection (Group 5, 64.7%) CPAK type 1 patients (Table 7 ). Specifically, while CPAK Type 1 patients demonstrated significant correction in mFTA and MPTA, mLDFA and JLCA remained stable, suggesting that the correction occurred predominantly on the tibial side. CPAK Type 4 patients similarly demonstrated significant mFTA and MPTA improvement. Only five knees were classified as CPAK Type 2 (with distal apex and neutral joint lines), and all of them transitioned to valgus phenotypes—Types 5 or 6—following surgery. In three patients with CPAK Type 5, the JLCA remained elevated postoperatively (7.67° ± 1.53° pre-op vs. 5.67° ± 2.08° post-op), while the MPTA increased from 90.67° ± 1.15° to 96.33° ± 2.08°, indicating overcorrection and persistent medial compartment overload (Table 8 ). While CPAK classification effectively characterizes coronal alignment phenotypes based on bony angular measurements, its interpretation in osteotomy should be cautious, given that intra-articular factors such as JLCA also influence overall mechanical axis and joint line orientation. Accordingly, JLCA was analyzed separately to account for its contribution to mechanical axis deviation and joint congruity. Table 6 The number and percentage of changes from preoperative CPAK type to postoperative CPAK type postop.CPAK type (count and % within preop. CPAK type) preop.CPAK type 1 2 3 4 5 6 7 8 9 1 (n = 121) 10 (8,3%) 9 (7,5%) 9 (7,5%) 14 (11,7%) 31 (25,6%) 19 (15,8%) 3 (2,5%) 10 (8,3%) 16 (13,2%) 4 (n = 18) 1 (5,6%) 0 (0,0%) 1 (5,6%) 0 (0,0%) 3 (16,7%) 4 (22,2%) 1 (5,6%) 4 (22,2%) 4 (22,2%) 2 (n = 5) 0 0 0 0 2 (40,0%) 3 (60,0%) 0 0 0 5 (n = 3) 0 0 0 0 0 0 1 (33,3%) 0 2 (66,7%) Total (n = 147) 11 (7,5%) 9 (6,3%) 10 (6,8%) 14 (9,4%) 36 (24.5%) 26 (17,7%) 5 (3,4%) 14 (9,4%) 22 (15,0%) Table 7 In CPAK type1, post-operative HSS scores by Groups MAD HSS Under 80 point Between 81–85 point Between 86–90 point Above 90 point Total (n) Group 1 12 (33.3%) 13 (36.1%) 11 (29.6%) - 36 Group 2 - 15 (44.1%) 16 (47.1%) 3 (8.8%) 34 Group 3 - 12 (63.2%) 6 (31.6%) 1 (5.3%) 19 Group 4 1 (7.1%) 7 (50.0%) 4 (28.6%) 2 (14.3%) 14 Group 5 11 (64.7%) 4 (23.5%) 2 (11.8%) - 17 Table 8 Detailed analysis of radiological parameters relative to preoperative CPAK types. preop. CPAK Type Preop. mFTA Postop.mFTA Preop. MPTA Postop. MPTA Preop. mLDFA Postop. mLDFA Preop. JLCA Postop. JLCA 1 N 121 121 121 121 121 121 121 121 Mean 187,71 178,70 81,80 90,68 89,26 89,55 1,79 1,79 Std. Dev. 3,222 3,999 2,477 4,329 2,177 2,455 1,454 1,251 4 N 18 18 18 18 18 18 18 18 Mean 188,00 177,31 85,54 92,50 91,76 89,85 3,61 2,61 Std. Dev. 3,495 3,911 3,434 4,086 2,287 3,869 2,182 1,605 2 N 5 5 5 5 5 5 5 5 Mean 185,60 177,20 86,40 92,40 87,40 87,80 3,60 2,60 Std. Dev. 2,702 3,347 1,673 2,881 0,894 0,837 3,435 1,140 5 N 3 3 3 3 3 3 3 3 Mean 187,67 179,33 90,67 96,33 91,00 91,33 7,67 5,67 Std. Dev. 1,155 0,577 1,155 2,082 1,000 1,528 1,528 2,082 Discussion The most important finding of this study is that the best clinical outcomes were observed in CPAK Type 5 patients—characterized by an apex neutral, neutral joint line—with a postoperative weight-bearing axis between 50% and 60%, corresponding to neutral or mild valgus alignment. These results highlight the value of phenotype-based, individualized alignment strategies that optimize joint line orientation and improve clinical outcomes, supporting a flexible, personalized approach to MOWHTO alignment correction rather than strict adherence to conventional targets. Previous studies have emphasized the critical role of coronal alignment in optimizing MOWHTO outcomes [ 2 , 3 , 15 – 18 ]. While the Fujisawa point has been widely used for its presumed biomechanical advantage in offloading the medial compartment, its rationale has been questioned. Amis et al. criticized its theoretical underpinnings, suggesting its clinical adoption is more tradition than science-based [ 19 ]. Supporting this, Martay et al. used finite element analysis to demonstrate that correction to 62–65% WBA reduces medial stress but may excessively load the lateral compartment. They proposed a 55% target (approximately 1.7°–1.9° valgus), aligned with the lateral tibial spine, as a more biomechanically balanced alternative [ 7 ]. This is consistent with more recent studies cautioning against overcorrection, especially when medial proximal tibial angle (MPTA) exceeds 95° or joint line obliquity (JLO) surpasses 4°, which may contribute to lateral compartment overload, shear stress on cartilage, and reduced patient satisfaction [ 20 – 26 ]. The European Society of Sports Traumatology, Knee Surgery & Arthroscopy (ESSKA) consensus has similarly recommended more conservative corrections to preserve joint biomechanics [ 27 ]. In our series, despite most patients not achieving the classical valgus target of 3°–6°, those corrected to a WBA between 50% and 60% demonstrated significantly improved clinical outcomes. These findings reinforce the notion that the "ideal correction" should be tailored to individual patient characteristics rather than rigidly defined by traditional targets. In addition to coronal alignment, joint line orientation is increasingly recognized as a key determinant of surgical success—not only in total knee arthroplasty (TKA) but also in MOWHTO. However, the interplay between CPAK phenotype, alignment parameters (MAD, MPTA, JLCA), and clinical outcomes in MOWHTO remains under-investigated [ 28 ]. The CPAK classification, by incorporating both mechanical axis and JLO, provides a more comprehensive framework for understanding alignment phenotypes. In particular, the presence of a distal apex—common in varus knees with medial compartment osteoarthritis. Incomplete correction of this obliquity may result in suboptimal load distribution, pain, and accelerated degeneration of the lateral compartment. Thus, optimal correction in MOWHTO should address both axis alignment and joint line orientation. Our analysis revealed a significant association between postoperative CPAK types and MAD groups (Pearson Chi-square = 54.931, p = 0.007), supporting the relevance of CPAK as a complementary tool to standard radiographic measurements. HSS scores improved significantly across all CPAK phenotypes (Wilcoxon Signed-Ranks Test, p = 0.001). CPAK Type 5, most frequently observed in the 50–60% WBA range, was associated with the most favorable outcomes. In contrast, patients with postoperative CPAK Type 9 were overcorrected (Group 5), and a significant portion of patients with postoperative CPAK Type 1 were in the undercorrected Group 1; in both groups, HSS scores were found to be lower. These findings highlight the importance of joint line orientation in MOWHTO and suggest that incorporating the CPAK classification into the assessment may contribute to improved functional outcomes. Limitations This study has several limitations. First, the follow-up period was relatively short, assessing only mid-term outcomes; thus, longer-term follow-up is needed. Second, as a retrospective analysis, the study included a heterogeneous patient population and small sample sizes within certain subgroups. Third, only the HSS score was used to evaluate clinical outcomes. While it is the standard outcome measure at our institution, it is not specifically validated for MOWHTO and may not capture subtle clinical differences. Future prospective studies should incorporate validated patient-reported outcome measures (PROMs) such as KOOS, IKDC, or WOMAC, as well as objective functional assessments. Additionally, target alignment may benefit from further individualization using patient-specific pathology, gait analysis, and computational modeling. Larger multicenter studies are warranted to validate our findings. Conclusion To our knowledge, few studies have examined the relationship between coronal alignment correction and knee phenotype in MOWHTO. Our results emphasize the value of phenotype-based, individualized alignment strategies that optimize joint line orientation and improve clinical outcomes. Further refinement is needed to develop osteotomy-specific classification systems that also integrate intra-articular and soft tissue considerations. Declarations Funding Declaration This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution Ahmet Can Erdem: designed the study and led the manuscript preparation. Vahdet Uçan: contributed to data collection and analysis. Gökhan Lebe: contributed to data collection and analysis.Cemil Burak Demirkıran: contributed to data collection and analysis.Muhammed Ali Geçkalan: contributed to data collection and analysis.Ali Toprak: contributed to statistical analysis.Nurzat Elmalı: He is corresponding author. He contributed to the design of the study, of the manuscript preparation and interpretation of results. All authors read and approved the final version of the manuscript. References Gomoll AH (2011) High tibial osteotomy for the treatment of unicompartmental knee osteoarthritis: a review of the literature, indications, and technique. Phys Sportsmed 39(3):45–54. https://doi.org/10.3810/PSM.2011.09.1920 ElAzab HM, Morgenstern M, Ahrens P, Schuster T, Imhoff AB, Lorenz SG (2011) Limb alignment after openwedge high tibial osteotomy and its effect on the clinical outcome. Orthopedics 34(10):e622–e628. https://doi.org/10.3928/01477447-20110826-02 Machado A, Micicoi L, Ernat J, Schippers P, de Dompsure RB, Bronsard N et al (2023) Normo or slightly overcorrection show better results after medial closing wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 31(10):4276–4284. https://doi.org/10.1007/s00167-023-07465-1 Lee SS, Lee HI, Cho ST, Cho JH (2020) Comparison of the outcomes between two different target points after open wedge high tibial osteotomy: the Fujisawa point versus the lateral tibial spine. Knee 27(3):915–922. https://doi.org/10.1016/j.knee.2020.01.007 Tripon M, Sautet P, Argenson JN, Jacquet C, Martz P, Ollivier M (2022) Is the lateral tibial spine a reliable landmark for planning tibial or femoral valgus osteotomies? Orthop Traumatol Surg Res 108(3):103253. https://doi.org/10.1016/j.otsr.2022.103253 Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P (2007) The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy 23(8):852–861. https://doi.org/10.1016/j.arthro.2007.05.018 Martay JL, Palmer AJ, Bangerter NK, Clare S, Monk AP, Brown CP, Price AJ (2018) A preliminary modeling investigation into the safe correction zone for high tibial osteotomy. Knee 25(2):286–295. https://doi.org/10.1016/j.knee.2017.12.006 Yin Y, Li S, Zhang R, Guo J, Hou Z, Zhang Y (2020) What is the relationship between the Fujisawa point and postoperative knee valgus angle? A theoretical, computerbased study. Knee 27(1):183–191. https://doi.org/10.1016/j.knee.2019.10.058 Heijens E, Kornherr P, Meister C (2016) The coronal hypomochlion: a tipping point of clinical relevance when planning valgusproducing high tibial osteotomies. Bone Joint J 98B(5):628–633. https://doi.org/10.1302/0301-620X.98B5.37867 MacDessi SJ, GriffithsJones W, Harris IA, Bellemans J, Chen DB (2020) The arithmetic HKA (aHKA) predicts the constitutional alignment of the arthritic knee compared to the normal contralateral knee: a matchedpairs radiographic study. Bone Joint Open 1(7):339–345. https://doi.org/10.1302/2633-1462.17.BJO-2020-0052.R1 Mitterer JA, Huber S, Pallamar M, Simon S, Nolte J, Chiari C, Hofstaetter J (2025) Changes of Knee Phenotypes Following Osteotomy Around the Knee in Patients with Valgus or Varus Deformities—A Retrospective CrossSectional Study. J Clin Med 14(13):4684. https://doi.org/10.3390/jcm14134684 Cho JH, Nam HS, Park SY, Ho JPY, Lee YS (2023) Constitutional and postoperative joint line obliquity can predict serial alignment change after openingwedge high tibial osteotomy: analysis using coronal plane alignment of the knee classification. Knee Surg Sports Traumatol Arthrosc 31(12):5652–5662. https://doi.org/10.1007/s00167-023-08617-x Kim SE, MacDessi SJ, Song D, Kim JI, Choi BS, Han HS et al (2024) Coronal Plane Alignment of the Knee (CPAK) type shifts toward constitutional varus with increasing Kellgren and Lawrence grade: a radiographic analysis of 17,365 knees. J Bone Joint Surg Am. https://doi.org/10.2106/JBJS.24.00316 Feucht MJ, Winkler PW, Mehl J, Bode G, Forkel P, Imhoff AB et al (2020) Isolated high tibial osteotomy is appropriate in less than twothirds of varus knees if excessive overcorrection of the medial proximal tibial angle should be avoided. Knee Surg Sports Traumatol Arthrosc (Epub 20 Jul 2020). https://doi.org/10.1007/s00167-020-05324-5 Mabrouk A, Fernandes LR, Jacquet C, Kley K, Claes S, Ollivier M (2024) The tipping point in medial opening wedge high tibial osteotomy relates to the shape of the proximal tibia more than to lower limb alignment correction. Knee Surg Sports Traumatol Arthrosc 32(4):1008–1015. https://doi.org/10.1007/s00167-023-07712-w Fujisawa Y, Masuhara K, Shiomi S (1979) The effect of high tibial osteotomy on osteoarthritis of the knee: an arthroscopic study of 54 knee joints. Orthop Clin North Am 10(3):585–594 (DOI bulunamadı; dergi arşivinden kontrol önerilir) Song JH, Bin SI, Kim JM, Lee BS (2020) What is an acceptable limit of jointline obliquity after medial open wedge high tibial osteotomy? Analysis based on midterm results. Am J Sports Med 48(12):3028–3035. https://doi.org/10.1177/0363546520967377 Van Bempt M, Van Genechten W, Claes T, Claes S (2016) How accurately does high tibial osteotomy correct the mechanical axis of an arthritic varus knee? A systematic review. Knee 23(6):925–935. https://doi.org/10.1007/s00167-015-3418-5 Amis AA (2013) Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21(1):197–205. https://doi.org/10.1007/s00167-012-2180-8 Nakayama H, Schroter S, Yamamoto C, Iseki T, Kanto R, Kurosaka K et al (2018) Large correction in opening wedge high tibial osteotomy with resultant jointline obliquity induces excessive shear stress on the articular cartilage. Knee Surg Sports Traumatol Arthrosc 26(6):1873–1878. https://doi.org/10.1007/s00167-017-4735-7 Goshima K, Sawaguchi T, Shigemoto K, Iwai S, Fujita K, Yamamuro Y (2019) Comparison of clinical and radiologic outcomes between normal and overcorrected medial proximal tibial angle groups after openwedge high tibial osteotomy. Arthroscopy 35(10):2898–2908e1. https://doi.org/10.1016/j.arthro.2019.05.059 Akamatsu Y, Kumagai K, Kobayashi H, Tsuji M, Saito T (2018) Effect of increased coronal inclination of the tibial plateau after openingwedge high tibial osteotomy. Arthroscopy 34(7):2158–2169e2. https://doi.org/10.1016/j.arthro.2018.02.033 Kim JS, Lim JK, Choi HG et al (2022) Excessively increased jointline obliquity after medial openingwedge high tibial osteotomy is associated with inferior radiologic and clinical outcomes: what is permissible jointline obliquity. Arthroscopy 38(6):1904–1915. https://doi.org/10.1016/j.arthro.2022.01.046 Kim GW, Kang JK, Song EK, Seon JK (2021) Increased joint obliquity after openwedge high tibial osteotomy induces pain in the lateral compartment: a comparative analysis of the minimum 4year followup outcomes using propensity score matching. Knee Surg Sports Traumatol Arthrosc 29(10):3495–3502. https://doi.org/10.1007/s00167-021-06510-2 Kuriyama S, Watanabe M, Nakamura S, Nishitani K, Tanaka Y, Sekiguchi K et al (2020) Large medial proximal tibial angles cause excessively medial tibiofemoral contact forces and abnormal knee kinematics following openwedge high tibial osteotomy. Clin Biomech 80:105190. https://doi.org/10.1016/j.clinbiomech.2020.105190 Atkinson HF, Birmingham TB, Schulz JM, Primeau CA, Leitch KM, Pritchett SL et al (2021) High tibial osteotomy to neutral alignment improves medial knee articular cartilage composition. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-021-06516-9 Jacobi M, Lording T, Hirschmann MT, Parker DA, Getgood A, Monllau JC et al (2023) ESSKA consensus on osteotomy: Indications, planning, surgical techniques and outcomes for osteotomies around the knee. Knee Surg Sports Traumatol Arthrosc 31(10):3743–3759. https://doi.org/10.1007/s00167-023-07333-z Victor JM, Bassens D, Bellemans J, Gürsu S, Dhollander AA, Verdonk PC (2014) Constitutional varus does not affect joint line orientation in the coronal plane. Clin Orthop Relat Res 472(1):98–104. https://doi.org/10.1007/s11999-013-3266-2 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Aug, 2025 Reviews received at journal 23 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviews received at journal 12 Aug, 2025 Reviewers agreed at journal 10 Aug, 2025 Reviewers invited by journal 05 Aug, 2025 Editor assigned by journal 29 Jul, 2025 Submission checks completed at journal 29 Jul, 2025 First submitted to journal 16 Jul, 2025 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. 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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-7142721","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497359611,"identity":"f8a02ee0-d573-47d4-90a9-7e69e513480a","order_by":0,"name":"Ahmetcan Erdem","email":"","orcid":"","institution":"Bezmialem Foundation University Medical Faculty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmetcan","middleName":"","lastName":"Erdem","suffix":""},{"id":497359612,"identity":"9f2b6247-06af-4fbe-bbb5-dca420247d82","order_by":1,"name":"Vahdet Uçan","email":"","orcid":"","institution":"Bezmialem Foundation University Medical Faculty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Vahdet","middleName":"","lastName":"Uçan","suffix":""},{"id":497359613,"identity":"71e7ccd5-9f41-459b-95c2-86981204f8b6","order_by":2,"name":"Gökhan Lebe","email":"","orcid":"","institution":"Bezmialem Foundation University Medical Faculty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gökhan","middleName":"","lastName":"Lebe","suffix":""},{"id":497359614,"identity":"d9d2badb-ba66-42f7-a82a-23a27ce7d5c0","order_by":3,"name":"Muhammet Ali Geçkalan","email":"","orcid":"","institution":"Bezmialem Foundation University Medical Faculty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Muhammet","middleName":"Ali","lastName":"Geçkalan","suffix":""},{"id":497359615,"identity":"82ed322d-0abb-4037-9680-5d63f95fa98d","order_by":4,"name":"Cemil Burak Demirkıran","email":"","orcid":"","institution":"Republic of Turkey Ministry of Health Saray State Hospital,","correspondingAuthor":false,"prefix":"","firstName":"Cemil","middleName":"Burak","lastName":"Demirkıran","suffix":""},{"id":497359616,"identity":"0494f78c-42e5-4744-a7a8-af6d2eec48ab","order_by":5,"name":"Ali Toprak","email":"","orcid":"","institution":"Bezmialem Foundation University Medical Faculty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Toprak","suffix":""},{"id":497359617,"identity":"bce58888-2448-4e9e-8945-43d7658ccc77","order_by":6,"name":"Nurzat Elmalı","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYFAC5gYGhgIJOQMwx8CCGC2MQC0GEsYGDMwgLRJEa2FI3ADWwkCEFnP2xtYNPwws0rez9x/d8KNAgoG/vTsBrxbLnoNtN3sMJHJ39hxmAzEYJM6c3YBXi8GNxLYbPEAtG24ks4EYDCA2fi33H7bd/GMgkW4A1AJiEKHlBmPbbaDhCSAtt4mz5Uxi220ZAwnDDWcOm4EYPIT9cvzwsZtvKurkDY43Prv55o+NHH97L34tGICHNOWjYBSMglEwCrACAJq+SBYp+SBWAAAAAElFTkSuQmCC","orcid":"","institution":"Bezmialem Foundation University Medical Faculty Hospital","correspondingAuthor":true,"prefix":"","firstName":"Nurzat","middleName":"","lastName":"Elmalı","suffix":""}],"badges":[],"createdAt":"2025-07-16 18:38:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7142721/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7142721/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88775154,"identity":"fb4d565f-afcf-49be-b086-da836a6e69b6","added_by":"auto","created_at":"2025-08-11 10:04:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26012,"visible":true,"origin":"","legend":"\u003cp\u003eshows postop. mFTA by groups Mechanical axis deviation (MAD)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7142721/v1/61d858480eba73e1270b4ff8.png"},{"id":88775156,"identity":"0864d375-fff1-4e11-a484-ef33782005b6","added_by":"auto","created_at":"2025-08-11 10:04:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":19735,"visible":true,"origin":"","legend":"\u003cp\u003eshows mMPTA by groups\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7142721/v1/269e90f1177373eda0bb0801.png"},{"id":88777479,"identity":"43b450a6-0feb-4c3f-916e-8da4bc9ed28b","added_by":"auto","created_at":"2025-08-11 10:12:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":61677,"visible":true,"origin":"","legend":"\u003cp\u003ePatient distribution by groups.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7142721/v1/001e2a444df85ec7ecafe6b9.png"},{"id":88775159,"identity":"c5f22ea6-4a43-4a16-a04e-871ce53c04bf","added_by":"auto","created_at":"2025-08-11 10:04:48","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":31435,"visible":true,"origin":"","legend":"\u003cp\u003eHSS score distribution significantly differs by groups.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7142721/v1/33d36646b2c2c80b1af34746.png"},{"id":88778093,"identity":"e6dcd4ac-278b-4930-b076-4e834714dd0b","added_by":"auto","created_at":"2025-08-11 10:20:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1014498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7142721/v1/c6969c27-31b2-4e59-bebb-c0af298be61b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Mechanical Axis Position and Coronal Plane Alignment Phenotypes on Clinical Outcomes in Medial Opening Wedge High Tibial Osteotomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedial opening wedge high tibial osteotomy (MOWHTO) is a well-established procedure for the treatment of medial compartment knee osteoarthritis (OA) with varus malalignment. By laterally shifting the mechanical load-bearing axis, MOWHTO unloads the degenerated medial compartment and alleviates pain, thereby improving function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Achieving optimal postoperative lower limb alignment is considered crucial for favourable clinical outcomes; however, there is still no consensus on the ideal correction target [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Recent biomechanical studies have raised concerns that excessive valgus (\u0026gt;\u0026thinsp;2\u0026deg;) may increase stress on the lateral compartment without providing additional clinical benefit [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe concept of constitutional alignment refers to the native coronal alignment of the limb prior to the onset of osteoarthritis. In healthy, pre-arthritic knees, the joint line is typically horizontal. However, disease progression disrupts this orientation, often leading to altered joint line obliquity (JLO). This change has increased interest in restoring physiological joint line orientation during corrective procedures. In this context, the Coronal Plane Alignment of the Knee (CPAK) classification system, introduced by MacDessi et al., provides a structured framework that categorizes knee alignment into nine phenotypes based on mechanical axis deviation and JLO. While CPAK was initially developed for total knee arthroplasty (TKA), its application to osteotomy represents a novel approach that may help tailor alignment strategies and refine surgical planning [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In MOWHTO, surgical objectives extend beyond lateralization of the mechanical axis; restoring a more horizontal joint line is also essential to optimize knee biomechanics. Importantly, not all varus knees share the same phenotype; accurate interpretation of joint line obliquity (JLO), particularly the direction of its apex, is essential for precise surgical planning. For instance, CPAK Types I and IV\u0026mdash;characterized by varus alignment and distal or neutral JLO\u0026mdash;are commonly associated with medial compartment OA and are typical targets for osteotomy. This heterogeneity should be considered in surgical planning. Postoperatively, conversion to valgus phenotypes such as Type VI (with neutral JLO) may reflect more favorable joint alignment and load distribution.\u003c/p\u003e\u003cp\u003eAlthough correction targets such as the Fujisawa point and mild valgus alignment have been studied in MOWHTO, few investigations have systematically examined alignment using the CPAK classification, which integrates both mechanical axis and JLO [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The potential utility of this system in improving individualized correction and predicting outcomes remains underexplored. The aims of this retrospective study were: (1) to investigate the impact of different postoperative alignment targets\u0026mdash;including deviations from the Fujisawa point\u0026mdash;on clinical outcomes following MOWHTO, (2) to analyze the distribution of CPAK phenotypes before and after surgery, and (3) to assess the relationship between CPAK phenotype, mechanical axis deviation, JLO, and clinical outcomes. To our knowledge, this is one of the first studies to apply the CPAK classification in the setting of MOWHTO, and it may provide new insights for phenotype-based, personalized alignment strategies.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis retrospective cohort study included 147 knees from 123 patients who underwent MOWHTO between 2017 and 2022 at a single institution, with a minimum clinical follow-up of 24 months. Ethical approval was obtained from the institutional review board of \u0026hellip;. The mean age of patients was 47.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3 years, with 45 males (36.5%) and 78 females (63.5%). Surgeries involved the right knee in 66 cases (44.9%) and the left knee in 81 cases (55.1%). Twelve patients had staged bilateral procedures, and eight underwent simultaneous anterior cruciate ligament reconstruction. The mean follow-up duration was 28.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 months. Osteoarthritis severity was graded using the Kellgren\u0026ndash;Lawrence system, with the majority classified as Stage 2 (n\u0026thinsp;=\u0026thinsp;66) or Stage 3 (n\u0026thinsp;=\u0026thinsp;69), and only 12 knees at Stage 4. Patients included in the study had provided written informed consent and presented primarily with anteromedial knee pain and medial compartment osteoarthritis. They were aged between 30 and 60 years, had full knee range of motion with flexion contracture less than 10\u0026deg;, and intact lateral compartment cartilage and menisci. Exclusion criteria were BMI over 35 kg/m\u0026sup2;, multicompartmental osteoarthritis, non-degenerative joint disease, prior major lower limb surgery, or complete loss of medial joint space on standing radiographs.\u003c/p\u003e\u003cp\u003eAll procedures were performed under spinal anesthesia. Initial diagnostic arthroscopy addressed intra-articular pathology, followed by a biplanar MOWHTO. The superficial medial collateral ligament was released subperiosteally. Two K-wires were inserted about 4 cm distal to the joint line toward the fibular head to guide the osteotomy. A horizontal cut was made above the patellar tendon insertion, with an ascending cut angled approximately 110\u0026deg; to the horizontal. A lateral cortical hinge of roughly 1 cm was preserved. The osteotomy gap was opened gradually with a laminar spreader, creating a trapezoidal defect wider posteromedially. Fixation was achieved using a TomoFix locking plate system.\u003c/p\u003e\u003cp\u003ePatients received intravenous cefuroxime 30 minutes before surgery and low-molecular-weight heparin (enoxaparin) for thromboprophylaxis over 10 days postoperatively. Rehabilitation started on day one with isometric and straight-leg-raising exercises. Toe-touch weight-bearing was permitted immediately, partial weight-bearing began at 3 weeks, and full weight-bearing was allowed at 6 weeks after radiographic confirmation of healing.\u003c/p\u003e\u003cp\u003eRadiographic evaluation utilized standardized, full-length, weight-bearing anteroposterior radiographs taken preoperatively and at final follow-up. Parameters measured included the mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA), arithmetic hip-knee-ankle angle (aHKA, calculated as MPTA minus mLDFA), and joint line obliquity (JLO, calculated as MPTA plus mLDFA). The weight-bearing line (WBL) position was expressed as a percentage of the tibial plateau width from medial (0%) to lateral (100%). Postoperative alignment was categorized into five groups: Group 1 with WBL less than 50% indicating undercorrection; Group 2 with WBL between 50 and 55% considered neutral; Group 3 with WBL 55\u0026ndash;60% representing mild valgus; Group 4 with WBL 60\u0026ndash;65% corresponding to the Fujisawa point; and Group 5 with WBL greater than 65%, indicating overcorrection.\u003c/p\u003e\u003cp\u003eKnee phenotypes were classified using the Coronal Plane Alignment of the Knee (CPAK) system, which incorporates mechanical axis deviation and joint line obliquity. Alignment was categorized based on aHKA as varus (\u0026thinsp;\u0026le;\u0026thinsp;\u0026minus;\u0026thinsp;2\u0026deg;), neutral (between \u0026minus;\u0026thinsp;2\u0026deg; and 2\u0026deg;), or valgus (\u0026ge;\u0026thinsp;2\u0026deg;). Joint line obliquity was classified as apex distal (JLO\u0026thinsp;\u0026le;\u0026thinsp;177\u0026deg;), apex neutral (177\u0026deg;\u0026ndash;183\u0026deg;), or apex proximal (\u0026ge;\u0026thinsp;183\u0026deg;). JLCA was graded as normal (\u0026le;\u0026thinsp;2\u0026deg;), increased (2\u0026deg;\u0026ndash;3\u0026deg;), or severely increased (\u0026ge;\u0026thinsp;4\u0026deg;), with a change of 2\u0026deg; or more considered clinically significant. The MPTA was classified as normal (85\u0026deg;\u0026ndash;90\u0026deg;), increased (90\u0026deg;\u0026ndash;95\u0026deg;), or severely increased (\u0026gt;\u0026thinsp;95\u0026deg;).\u003c/p\u003e\u003cp\u003eFunctional outcomes were evaluated using the Hospital for Special Surgery (HSS) knee score at baseline and final follow-up, with scores categorized as fair (70\u0026ndash;80), good (81\u0026ndash;85), very good (86\u0026ndash;90), or excellent (\u0026gt;\u0026thinsp;90).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was conducted using IBM SPSS Statistics for Windows, Version 29.0.2. Descriptive statistics summarized patient characteristics and outcomes. Group comparisons used one-way ANOVA for normally distributed variables and the Kruskal\u0026ndash;Wallis test for non-parametric data, with post hoc testing as needed. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePreoperative analysis showed no statistically significant differences among groups regarding age, sex distribution, side of surgery, alignment parameters (mFTA, mMPTA, mLDFA, JLCA), or functional outcome scores (HSS), with all p-values\u0026thinsp;\u0026gt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eBoth mFTA and mMPTA showed significant pre- to postoperative changes across groups (Kruskal-Wallis test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The aHKA improved from \u0026minus;\u0026thinsp;7.35\u0026deg; (varus) to +\u0026thinsp;1.59\u0026deg; (slight valgus), representing a mean correction of +\u0026thinsp;8.74\u0026deg; (t\u0026thinsp;=\u0026thinsp;21.621, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Joint line orientation (JLO) was corrected from 172.4\u0026deg; to 180.8\u0026deg; (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating effective horizontalization of the joint line. In contrast, mLDFA remained essentially unchanged (+\u0026thinsp;0.09\u0026deg;, t\u0026thinsp;=\u0026thinsp;0.448, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting no significant femoral side correction. The joint line convergence angle (JLCA) also showed a non-significant change of +\u0026thinsp;0.16\u0026deg; (t\u0026thinsp;=\u0026thinsp;1.506, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating preserved joint space alignment.\u003c/p\u003e\u003cp\u003eThe Hospital for Special Surgery (HSS) score improved significantly by 50.12 points (t\u0026thinsp;=\u0026thinsp;78.002, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reflecting substantial clinical improvement in pain relief and knee function (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Functional outcomes across groups showed significant postoperative HSS score improvements (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Notably, groups 1 and 5 recorded the lowest HSS scores (84.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 and 82.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3, respectively), suggesting that both undercorrection and overcorrection adversely affect clinical outcomes (p\u0026thinsp;=\u0026thinsp;0.002). Group 5 exhibited the highest mMPTA (94.0\u0026deg; \u0026plusmn; 4.2\u0026deg;), consistent with overcorrection and joint line obliquity. Patients with severely increased JLCA (\u0026ge;\u0026thinsp;4\u0026deg;) tended to have lower HSS scores, with only 6.9% achieving excellent results (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of preoperative and postoperative measurements\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeasurement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreoperative Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostoperative Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean Difference\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003emFTA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e187.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e178.45\u0026thinsp;\u0026plusmn;\u0026thinsp;3.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-9.31\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e25.337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMPTA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e82.56\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e91.05\u0026thinsp;\u0026plusmn;\u0026thinsp;4.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;8.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.936\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003emLDFA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e89.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e89.62\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.448\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eaHKA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-7.35\u0026thinsp;\u0026plusmn;\u0026thinsp;3.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;8.74\u0026thinsp;\u0026plusmn;\u0026thinsp;4.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.621\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eJLO\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e172.40\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e180.80\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;8.39\u0026thinsp;\u0026plusmn;\u0026thinsp;5.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18.314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eJLCA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.506\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHSS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e35.73\u0026thinsp;\u0026plusmn;\u0026thinsp;7.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e85.85\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;50.12\u0026thinsp;\u0026plusmn;\u0026thinsp;7.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e78.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003emFTA: Mechanical femorotibial angle, MPTA: Medial proximal tibial angle, mLDFA: Mechanical lateral distal femoral angle, aHKA: Arithmetic hip knee angle, JLO: Joint line obliquity, JLCA: Joint line convergence angle\u003c/p\u003e\u003cp\u003eHSS: Hospital for special surgery\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostop. clinical scores and radiologic characteristics according to groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostop.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGroup 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGroup 4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGroup 5\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNo of Patients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44 (29.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21 (14.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15 (10.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e25 (17.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHSS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e84.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e87.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e88.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e82.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eΔ HSS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-5.661\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-5.802\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-4.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-3.441\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-4.414\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003emFTA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e181.05\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e178.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e178.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e177.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e174.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003emMPTA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e88.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e91.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e90.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e92.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e94.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003emLDFA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e90.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e89.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e88.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e89.04\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eaHKA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eJLCA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.47\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eJLO\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eValues are shown as n (%) or mean \u0026plusmn; standart deviations, Group 1 (WBL\u0026thinsp;\u0026lt;\u0026thinsp;50%), Group 2 (WBL\u0026thinsp;=\u0026thinsp;50\u0026ndash;55%), Group 3 (WBL\u0026thinsp;=\u0026thinsp;55\u0026ndash;60%), Group 4 (WBL\u0026thinsp;=\u0026thinsp;60\u0026ndash;65), and Group 5 (WBL\u0026thinsp;\u0026gt;\u0026thinsp;65%). HSS: Hospital for Special Surgery. The \u003cb\u003eΔ HSS\u003c/b\u003e (postop - preop) was consistently negative across all groups, indicating substantial improvement postoperatively.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eshows Clinical scores (HSS) according to groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHSS score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGroup 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGroup 4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGroup 5\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;80 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e81\u0026ndash;85 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e86\u0026ndash;90 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;90 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eJLCA groups and postop. HSS scores (P\u0026thinsp;\u0026gt;\u0026thinsp;0.005)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHSS score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup 1 (\u0026lt;\u0026thinsp;2)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup 2 (2\u0026ndash;4)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGroup 3 (\u0026gt;\u0026thinsp;4)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;80 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (24.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (14.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e81\u0026ndash;85 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28 (40.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37 (52.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (42.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e86\u0026ndash;90 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;90 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (7.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMPTA groups and postop.HSS scores (P\u0026thinsp;\u0026gt;\u0026thinsp;0.005)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHSS Score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMPTA\u0026thinsp;\u0026lt;\u0026thinsp;90\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMPTA 90\u0026ndash;95\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMPTA\u0026thinsp;\u0026gt;\u0026thinsp;95\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;80 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12 (41.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (34.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7 (24.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e81\u0026ndash;85 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28 (41.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26 (38.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14 (20.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e86\u0026ndash;90 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (35.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16 (38.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11 (26.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;90 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (37.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePreoperative CPAK Type 1 was most prevalent (121/147 knees, 82.3%), characterized by varus alignment with apex distal joint lines, indicating tibial deformity and joint line obliquity. CPAK Type 4 accounted for 18 knees (17.7%) with varus alignment and apex neutral joint lines, primarily reflecting bony deformity without joint line tilt. Postoperatively, many Type 1 patients transitioned to CPAK Type 5 (neutral mechanical axis, apex neutral joint line; n\u0026thinsp;=\u0026thinsp;36, 24.5%) or Type 6 (valgus alignment, apex neutral joint line; n\u0026thinsp;=\u0026thinsp;26, 17.7%) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Clinical outcomes improved significantly across all CPAK groups postoperatively (Wilcoxon signed ranks test, p\u0026thinsp;=\u0026thinsp;0.001). Lower HSS scores were associated with both undercorrection (Group 1, 33.3%) and overcorrection (Group 5, 64.7%) CPAK type 1 patients (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Specifically, while CPAK Type 1 patients demonstrated significant correction in mFTA and MPTA, mLDFA and JLCA remained stable, suggesting that the correction occurred predominantly on the tibial side. CPAK Type 4 patients similarly demonstrated significant mFTA and MPTA improvement. Only five knees were classified as CPAK Type 2 (with distal apex and neutral joint lines), and all of them transitioned to valgus phenotypes\u0026mdash;Types 5 or 6\u0026mdash;following surgery. In three patients with CPAK Type 5, the JLCA remained elevated postoperatively (7.67\u0026deg; \u0026plusmn; 1.53\u0026deg; pre-op vs. 5.67\u0026deg; \u0026plusmn; 2.08\u0026deg; post-op), while the MPTA increased from 90.67\u0026deg; \u0026plusmn; 1.15\u0026deg; to 96.33\u0026deg; \u0026plusmn; 2.08\u0026deg;, indicating overcorrection and persistent medial compartment overload (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). While CPAK classification effectively characterizes coronal alignment phenotypes based on bony angular measurements, its interpretation in osteotomy should be cautious, given that intra-articular factors such as JLCA also influence overall mechanical axis and joint line orientation. Accordingly, JLCA was analyzed separately to account for its contribution to mechanical axis deviation and joint congruity.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe number and percentage of changes from preoperative CPAK type to postoperative CPAK type\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"9\" nameend=\"c10\" namest=\"c2\"\u003e\u003cp\u003epostop.CPAK type (count and % within preop. CPAK type)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epreop.CPAK type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1 (n\u0026thinsp;=\u0026thinsp;121)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (8,3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (7,5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (7,5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 (11,7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31 (25,6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19 (15,8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3 (2,5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e10 (8,3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e16 (13,2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4 (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5,6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0,0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (5,6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0,0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3 (16,7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4 (22,2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (5,6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e4 (22,2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e4 (22,2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2 (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (40,0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3 (60,0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 (33,3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2 (66,7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;147)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (7,5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (6,3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (6,8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 (9,4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36 (24.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e26 (17,7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5 (3,4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e14 (9,4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e22 (15,0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIn CPAK type1, post-operative HSS scores by Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMAD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eHSS\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnder 80 point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBetween 81\u0026ndash;85 point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBetween 86\u0026ndash;90 point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAbove 90 point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eTotal (n)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGroup 1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (36.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11 (29.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGroup 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15 (44.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16 (47.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGroup 3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12 (63.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6 (31.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGroup 4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (7.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (14.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGroup 5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (64.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (23.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2 (11.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDetailed analysis of \u003cb\u003eradiological parameters\u003c/b\u003e relative to preoperative \u003cb\u003eCPAK\u003c/b\u003e types.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003epreop.\u0026nbsp;\u0026nbsp; CPAK Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePreop. mFTA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePostop.mFTA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePreop. MPTA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePostop. MPTA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePreop. mLDFA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePostop. mLDFA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ePreop. JLCA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003ePostop.\u0026nbsp; JLCA\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e187,71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e178,70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e81,80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e90,68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e89,26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e89,55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1,79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1,79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStd. Dev.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,222\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3,999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2,477\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4,329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2,177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2,455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1,454\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1,251\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e188,00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e177,31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e85,54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e92,50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e91,76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e89,85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e3,61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e2,61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStd. Dev.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,495\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3,911\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3,434\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4,086\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2,287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3,869\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e2,182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1,605\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e185,60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e177,20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e86,40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e92,40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e87,40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e87,80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e3,60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e2,60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStd. Dev.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,702\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3,347\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1,673\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2,881\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0,894\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0,837\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e3,435\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1,140\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e187,67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e179,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e90,67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e96,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e91,00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e91,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e7,67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5,67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStd. Dev.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0,577\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1,155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2,082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,528\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1,528\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e2,082\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding of this study is that the best clinical outcomes were observed in CPAK Type 5 patients\u0026mdash;characterized by an apex neutral, neutral joint line\u0026mdash;with a postoperative weight-bearing axis between 50% and 60%, corresponding to neutral or mild valgus alignment. These results highlight the value of phenotype-based, individualized alignment strategies that optimize joint line orientation and improve clinical outcomes, supporting a flexible, personalized approach to MOWHTO alignment correction rather than strict adherence to conventional targets.\u003c/p\u003e\u003cp\u003ePrevious studies have emphasized the critical role of coronal alignment in optimizing MOWHTO outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While the Fujisawa point has been widely used for its presumed biomechanical advantage in offloading the medial compartment, its rationale has been questioned. Amis et al. criticized its theoretical underpinnings, suggesting its clinical adoption is more tradition than science-based [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Supporting this, Martay et al. used finite element analysis to demonstrate that correction to 62\u0026ndash;65% WBA reduces medial stress but may excessively load the lateral compartment. They proposed a 55% target (approximately 1.7\u0026deg;\u0026ndash;1.9\u0026deg; valgus), aligned with the lateral tibial spine, as a more biomechanically balanced alternative [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This is consistent with more recent studies cautioning against overcorrection, especially when medial proximal tibial angle (MPTA) exceeds 95\u0026deg; or joint line obliquity (JLO) surpasses 4\u0026deg;, which may contribute to lateral compartment overload, shear stress on cartilage, and reduced patient satisfaction [\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The European Society of Sports Traumatology, Knee Surgery \u0026amp; Arthroscopy (ESSKA) consensus has similarly recommended more conservative corrections to preserve joint biomechanics [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In our series, despite most patients not achieving the classical valgus target of 3\u0026deg;\u0026ndash;6\u0026deg;, those corrected to a WBA between 50% and 60% demonstrated significantly improved clinical outcomes. These findings reinforce the notion that the \"ideal correction\" should be tailored to individual patient characteristics rather than rigidly defined by traditional targets.\u003c/p\u003e\u003cp\u003eIn addition to coronal alignment, joint line orientation is increasingly recognized as a key determinant of surgical success\u0026mdash;not only in total knee arthroplasty (TKA) but also in MOWHTO. However, the interplay between CPAK phenotype, alignment parameters (MAD, MPTA, JLCA), and clinical outcomes in MOWHTO remains under-investigated [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The CPAK classification, by incorporating both mechanical axis and JLO, provides a more comprehensive framework for understanding alignment phenotypes. In particular, the presence of a distal apex\u0026mdash;common in varus knees with medial compartment osteoarthritis. Incomplete correction of this obliquity may result in suboptimal load distribution, pain, and accelerated degeneration of the lateral compartment. Thus, optimal correction in MOWHTO should address both axis alignment and joint line orientation.\u003c/p\u003e\u003cp\u003eOur analysis revealed a significant association between postoperative CPAK types and MAD groups (Pearson Chi-square\u0026thinsp;=\u0026thinsp;54.931, p\u0026thinsp;=\u0026thinsp;0.007), supporting the relevance of CPAK as a complementary tool to standard radiographic measurements. HSS scores improved significantly across all CPAK phenotypes (Wilcoxon Signed-Ranks Test, p\u0026thinsp;=\u0026thinsp;0.001). CPAK Type 5, most frequently observed in the 50\u0026ndash;60% WBA range, was associated with the most favorable outcomes. In contrast, patients with postoperative CPAK Type 9 were overcorrected (Group 5), and a significant portion of patients with postoperative CPAK Type 1 were in the undercorrected Group 1; in both groups, HSS scores were found to be lower. These findings highlight the importance of joint line orientation in MOWHTO and suggest that incorporating the CPAK classification into the assessment may contribute to improved functional outcomes.\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the follow-up period was relatively short, assessing only mid-term outcomes; thus, longer-term follow-up is needed. Second, as a retrospective analysis, the study included a heterogeneous patient population and small sample sizes within certain subgroups. Third, only the HSS score was used to evaluate clinical outcomes. While it is the standard outcome measure at our institution, it is not specifically validated for MOWHTO and may not capture subtle clinical differences. Future prospective studies should incorporate validated patient-reported outcome measures (PROMs) such as KOOS, IKDC, or WOMAC, as well as objective functional assessments. Additionally, target alignment may benefit from further individualization using patient-specific pathology, gait analysis, and computational modeling. Larger multicenter studies are warranted to validate our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo our knowledge, few studies have examined the relationship between coronal alignment correction and knee phenotype in MOWHTO. Our results emphasize the value of phenotype-based, individualized alignment strategies that optimize joint line orientation and improve clinical outcomes. Further refinement is needed to develop osteotomy-specific classification systems that also integrate intra-articular and soft tissue considerations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding Declaration\u003c/h2\u003e\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\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAhmet Can Erdem: designed the study and led the manuscript preparation. Vahdet U\u0026ccedil;an: contributed to data collection and analysis. G\u0026ouml;khan Lebe: contributed to data collection and analysis.Cemil Burak Demirkıran: contributed to data collection and analysis.Muhammed Ali Ge\u0026ccedil;kalan: contributed to data collection and analysis.Ali Toprak: contributed to statistical analysis.Nurzat Elmalı: He is corresponding author. He contributed to the design of the study, of the manuscript preparation and interpretation of results. All authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGomoll AH (2011) High tibial osteotomy for the treatment of unicompartmental knee osteoarthritis: a review of the literature, indications, and technique. Phys Sportsmed 39(3):45\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3810/PSM.2011.09.1920\u003c/span\u003e\u003cspan address=\"10.3810/PSM.2011.09.1920\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElAzab HM, Morgenstern M, Ahrens P, Schuster T, Imhoff AB, Lorenz SG (2011) Limb alignment after openwedge high tibial osteotomy and its effect on the clinical outcome. Orthopedics 34(10):e622\u0026ndash;e628. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3928/01477447-20110826-02\u003c/span\u003e\u003cspan address=\"10.3928/01477447-20110826-02\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMachado A, Micicoi L, Ernat J, Schippers P, de Dompsure RB, Bronsard N et al (2023) Normo or slightly overcorrection show better results after medial closing wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 31(10):4276\u0026ndash;4284. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-023-07465-1\u003c/span\u003e\u003cspan address=\"10.1007/s00167-023-07465-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee SS, Lee HI, Cho ST, Cho JH (2020) Comparison of the outcomes between two different target points after open wedge high tibial osteotomy: the Fujisawa point versus the lateral tibial spine. Knee 27(3):915\u0026ndash;922. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.knee.2020.01.007\u003c/span\u003e\u003cspan address=\"10.1016/j.knee.2020.01.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTripon M, Sautet P, Argenson JN, Jacquet C, Martz P, Ollivier M (2022) Is the lateral tibial spine a reliable landmark for planning tibial or femoral valgus osteotomies? Orthop Traumatol Surg Res 108(3):103253. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.otsr.2022.103253\u003c/span\u003e\u003cspan address=\"10.1016/j.otsr.2022.103253\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P (2007) The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy 23(8):852\u0026ndash;861. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arthro.2007.05.018\u003c/span\u003e\u003cspan address=\"10.1016/j.arthro.2007.05.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartay JL, Palmer AJ, Bangerter NK, Clare S, Monk AP, Brown CP, Price AJ (2018) A preliminary modeling investigation into the safe correction zone for high tibial osteotomy. Knee 25(2):286\u0026ndash;295. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.knee.2017.12.006\u003c/span\u003e\u003cspan address=\"10.1016/j.knee.2017.12.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYin Y, Li S, Zhang R, Guo J, Hou Z, Zhang Y (2020) What is the relationship between the Fujisawa point and postoperative knee valgus angle? A theoretical, computerbased study. Knee 27(1):183\u0026ndash;191. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.knee.2019.10.058\u003c/span\u003e\u003cspan address=\"10.1016/j.knee.2019.10.058\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeijens E, Kornherr P, Meister C (2016) The coronal hypomochlion: a tipping point of clinical relevance when planning valgusproducing high tibial osteotomies. Bone Joint J 98B(5):628\u0026ndash;633. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1302/0301-620X.98B5.37867\u003c/span\u003e\u003cspan address=\"10.1302/0301-620X.98B5.37867\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacDessi SJ, GriffithsJones W, Harris IA, Bellemans J, Chen DB (2020) The arithmetic HKA (aHKA) predicts the constitutional alignment of the arthritic knee compared to the normal contralateral knee: a matchedpairs radiographic study. Bone Joint Open 1(7):339\u0026ndash;345. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1302/2633-1462.17.BJO-2020-0052.R1\u003c/span\u003e\u003cspan address=\"10.1302/2633-1462.17.BJO-2020-0052.R1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMitterer JA, Huber S, Pallamar M, Simon S, Nolte J, Chiari C, Hofstaetter J (2025) Changes of Knee Phenotypes Following Osteotomy Around the Knee in Patients with Valgus or Varus Deformities\u0026mdash;A Retrospective CrossSectional Study. J Clin Med 14(13):4684. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/jcm14134684\u003c/span\u003e\u003cspan address=\"10.3390/jcm14134684\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCho JH, Nam HS, Park SY, Ho JPY, Lee YS (2023) Constitutional and postoperative joint line obliquity can predict serial alignment change after openingwedge high tibial osteotomy: analysis using coronal plane alignment of the knee classification. Knee Surg Sports Traumatol Arthrosc 31(12):5652\u0026ndash;5662. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-023-08617-x\u003c/span\u003e\u003cspan address=\"10.1007/s00167-023-08617-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim SE, MacDessi SJ, Song D, Kim JI, Choi BS, Han HS et al (2024) Coronal Plane Alignment of the Knee (CPAK) type shifts toward constitutional varus with increasing Kellgren and Lawrence grade: a radiographic analysis of 17,365 knees. J Bone Joint Surg Am. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/JBJS.24.00316\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.24.00316\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeucht MJ, Winkler PW, Mehl J, Bode G, Forkel P, Imhoff AB et al (2020) Isolated high tibial osteotomy is appropriate in less than twothirds of varus knees if excessive overcorrection of the medial proximal tibial angle should be avoided. Knee Surg Sports Traumatol Arthrosc (Epub 20 Jul 2020). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-020-05324-5\u003c/span\u003e\u003cspan address=\"10.1007/s00167-020-05324-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMabrouk A, Fernandes LR, Jacquet C, Kley K, Claes S, Ollivier M (2024) The tipping point in medial opening wedge high tibial osteotomy relates to the shape of the proximal tibia more than to lower limb alignment correction. Knee Surg Sports Traumatol Arthrosc 32(4):1008\u0026ndash;1015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-023-07712-w\u003c/span\u003e\u003cspan address=\"10.1007/s00167-023-07712-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFujisawa Y, Masuhara K, Shiomi S (1979) The effect of high tibial osteotomy on osteoarthritis of the knee: an arthroscopic study of 54 knee joints. Orthop Clin North Am 10(3):585\u0026ndash;594 (DOI bulunamadı; dergi arşivinden kontrol \u0026ouml;nerilir)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSong JH, Bin SI, Kim JM, Lee BS (2020) What is an acceptable limit of jointline obliquity after medial open wedge high tibial osteotomy? Analysis based on midterm results. Am J Sports Med 48(12):3028\u0026ndash;3035. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0363546520967377\u003c/span\u003e\u003cspan address=\"10.1177/0363546520967377\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Bempt M, Van Genechten W, Claes T, Claes S (2016) How accurately does high tibial osteotomy correct the mechanical axis of an arthritic varus knee? A systematic review. Knee 23(6):925\u0026ndash;935. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-015-3418-5\u003c/span\u003e\u003cspan address=\"10.1007/s00167-015-3418-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmis AA (2013) Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21(1):197\u0026ndash;205. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-012-2180-8\u003c/span\u003e\u003cspan address=\"10.1007/s00167-012-2180-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakayama H, Schroter S, Yamamoto C, Iseki T, Kanto R, Kurosaka K et al (2018) Large correction in opening wedge high tibial osteotomy with resultant jointline obliquity induces excessive shear stress on the articular cartilage. Knee Surg Sports Traumatol Arthrosc 26(6):1873\u0026ndash;1878. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-017-4735-7\u003c/span\u003e\u003cspan address=\"10.1007/s00167-017-4735-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoshima K, Sawaguchi T, Shigemoto K, Iwai S, Fujita K, Yamamuro Y (2019) Comparison of clinical and radiologic outcomes between normal and overcorrected medial proximal tibial angle groups after openwedge high tibial osteotomy. Arthroscopy 35(10):2898\u0026ndash;2908e1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arthro.2019.05.059\u003c/span\u003e\u003cspan address=\"10.1016/j.arthro.2019.05.059\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkamatsu Y, Kumagai K, Kobayashi H, Tsuji M, Saito T (2018) Effect of increased coronal inclination of the tibial plateau after openingwedge high tibial osteotomy. Arthroscopy 34(7):2158\u0026ndash;2169e2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arthro.2018.02.033\u003c/span\u003e\u003cspan address=\"10.1016/j.arthro.2018.02.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim JS, Lim JK, Choi HG et al (2022) Excessively increased jointline obliquity after medial openingwedge high tibial osteotomy is associated with inferior radiologic and clinical outcomes: what is permissible jointline obliquity. Arthroscopy 38(6):1904\u0026ndash;1915. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arthro.2022.01.046\u003c/span\u003e\u003cspan address=\"10.1016/j.arthro.2022.01.046\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim GW, Kang JK, Song EK, Seon JK (2021) Increased joint obliquity after openwedge high tibial osteotomy induces pain in the lateral compartment: a comparative analysis of the minimum 4year followup outcomes using propensity score matching. Knee Surg Sports Traumatol Arthrosc 29(10):3495\u0026ndash;3502. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-021-06510-2\u003c/span\u003e\u003cspan address=\"10.1007/s00167-021-06510-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuriyama S, Watanabe M, Nakamura S, Nishitani K, Tanaka Y, Sekiguchi K et al (2020) Large medial proximal tibial angles cause excessively medial tibiofemoral contact forces and abnormal knee kinematics following openwedge high tibial osteotomy. Clin Biomech 80:105190. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clinbiomech.2020.105190\u003c/span\u003e\u003cspan address=\"10.1016/j.clinbiomech.2020.105190\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtkinson HF, Birmingham TB, Schulz JM, Primeau CA, Leitch KM, Pritchett SL et al (2021) High tibial osteotomy to neutral alignment improves medial knee articular cartilage composition. Knee Surg Sports Traumatol Arthrosc. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-021-06516-9\u003c/span\u003e\u003cspan address=\"10.1007/s00167-021-06516-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJacobi M, Lording T, Hirschmann MT, Parker DA, Getgood A, Monllau JC et al (2023) ESSKA consensus on osteotomy: Indications, planning, surgical techniques and outcomes for osteotomies around the knee. Knee Surg Sports Traumatol Arthrosc 31(10):3743\u0026ndash;3759. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-023-07333-z\u003c/span\u003e\u003cspan address=\"10.1007/s00167-023-07333-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVictor JM, Bassens D, Bellemans J, G\u0026uuml;rsu S, Dhollander AA, Verdonk PC (2014) Constitutional varus does not affect joint line orientation in the coronal plane. Clin Orthop Relat Res 472(1):98\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11999-013-3266-2\u003c/span\u003e\u003cspan address=\"10.1007/s11999-013-3266-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"High tibial osteotomy, mechanical axis alignment, coronal plane alignment, CPAK classification, joint line obliquity, knee osteoarthritis, clinical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-7142721/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7142721/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003cbr\u003e\nMedial opening wedge high tibial osteotomy (MOWHTO) is a widely used surgical technique for treating varus-aligned medial compartment knee osteoarthritis. While traditional strategies emphasize lateralizing the mechanical axis toward the Fujisawa point, recent biomechanical insights suggest that excessive valgus correction (\u0026gt;2°) may increase stress on the lateral compartment without conferring additional clinical benefit. Moreover, restoring a horizontal joint line is essential to optimize load distribution and improve knee function. The Coronal Plane Alignment of the Knee (CPAK) classification provides a phenotype-based framework that incorporates both mechanical axis deviation and joint line obliquity (JLO), though its application in MOWHTO remains underexplored.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and Methods:\u003c/strong\u003e\u003cbr\u003e\nA retrospective study was conducted on 147 knees in 123 patients who underwent MOWHTO with a minimum follow-up of 24 months. Radiographic parameters evaluated included mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA), arithmetic hip-knee-ankle angle (aHKA), and JLO. Patients were categorized into five groups based on postoperative weight-bearing line (WBL) position across the tibial plateau. CPAK phenotypes were recorded pre- and postoperatively. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) knee score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nCPAK type I (varus alignment with distal apex) was the predominant preoperative phenotype (82.3%). Postoperatively, a notable proportion of knees transitioned to CPAK types V (24.5%) and VI (17.7%), both associated with significantly higher HSS scores (p \u0026lt; 0.001). The mean aHKA improved from −7.35° to +1.59° (p \u0026lt; 0.001), and JLO corrected from 172.4° to 180.8° (p \u0026lt; 0.001), reflecting joint line horizontalization. JLCA remained stable (p \u0026gt; 0.05). Clinical outcomes were most favourable in patients with postoperative WBL positions between 50% and 60%, comparable to outcomes achieved at the Fujisawa point.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nSuccessful outcomes in MOWHTO depend not only on lateralization of the mechanical axis but also on restoring joint line orientation. This study is among the first to apply the CPAK classification to MOWHTO and demonstrates its potential for guiding phenotype-based, individualized correction strategies. Targeting a WBL position between 50% and 60%, along with horizontal joint line restoration, appears to optimize clinical results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence:\u003c/strong\u003eLevel III (retrospective comparative study)\u003c/p\u003e","manuscriptTitle":"Impact of Mechanical Axis Position and Coronal Plane Alignment Phenotypes on Clinical Outcomes in Medial Opening Wedge High Tibial Osteotomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 10:04:43","doi":"10.21203/rs.3.rs-7142721/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-25T20:36:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T14:41:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137318729544147513450169027470041665179","date":"2025-08-14T13:40:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-12T14:23:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"218544647574364740623498077391243517691","date":"2025-08-10T07:47:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-05T23:30:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-29T13:04:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-29T13:01:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Orthopaedics","date":"2025-07-16T18:22:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f741db1a-201a-4263-b01e-68c87021eb33","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-17T01:08:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-11 10:04:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7142721","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7142721","identity":"rs-7142721","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}