Gait & Posture 57 (2017) 5768

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Gait & Posture

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Full length article

Change in gait after high tibial osteotomy: A systematic review MARK

and meta-analysis

Seung Hoon Leea, O-Sung Leea, Seow Hui Teob, Yong Seuk Leea,
a
Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
b
Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence in Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya,
Malaysia

A R T I C L E I N F O A B S T R A C T

Keywords: We conducted a meta-analysis to analyze how high tibial osteotomy (HTO) changes gait and focused on the
Knee following questions: (1) How does HTO change basic gait variables? (2) How does HTO change the gait variables
Osteoarthritis in the knee joint? Twelve articles were included in the nal analysis. A total of 383 knees was evaluated. There
High tibial osteotomy were 237 open wedge (OW) and 143 closed wedge (CW) HTOs. There were 4 level II studies and 8 level III
Gait analysis
studies. All studies included gait analysis and compared pre- and postoperative values. One study compared
Knee adduction moment
CWHTO and unicompartmental knee arthroplasty (UKA), and another study compared CWHTO and OWHTO.
Five studies compared gait variables with those of healthy controls. One study compared operated limb gait
variables with those in the non-operated limb. Gait speed, stride length, knee adduction moment, and lateral
thrust were major variables assessed in 2 or more studies. Walking speed increased and stride length was
increased or similar after HTO compared to the preoperative value in basic gait variables. Knee adduction
moment and lateral thrust were decreased after HTO compared to the preoperative knee joint gait variables.
Change in co-contraction of the medial side muscle after surgery diered depending on the degree of frontal
plane alignment. The relationship between change in knee adduction moment and change in mechanical axis
angle was controversial. Based on our systematic review and meta-analysis, walking speed and stride length
increased after HTO. Knee adduction moment and lateral thrust decreased after HTO compared to the
preoperative values of gait variables in the knee joint.

1. Introduction [1417]. Clinical outcomes and problems associated with CW and OW

Recent studies evaluating mechanical risk factors for progression of
knee osteoarthritis show that malalignment and distribution of tibiofe-
moral loads play an important role. In particular, large adduction
moment, frontal plane laxity, and muscle co-contraction may have
adverse eects on the knee joint due to increased compressive loads
across the joint, possibly accelerating the progression of osteoarthritis
[17]. Over time, the greater adduction moment coupled with high
muscle co-contraction may have adverse eects on the knee joint
[1,8,9].
High tibial osteotomy (HTO) is recognized as a successful treatment
option for medial compartment osteoarthritis of the knee joint by
producing a valgus limb alignment and shifting the load-bearing axis of
the lower extremity laterally [1013]. Among several procedures, open-
(OW) or closed-wedge (CW) HTO is the most popular; each technique
has advantages and disadvantages, and neither is superior to the other
have been reported in many articles and these studies usually compare
subjective symptoms and static data such as radiologic outcomes [18].
Biomechanical factors such as walking in activities of daily living
would be more relevant if we consider the decreased load on the medial
knee compartment as the primary rationale of HTO. Three-dimensional
gait analysis has been used to demonstrate that, in addition to restoring
more normal static alignment of the lower limb, HTO is also successful
in modifying the knee biomechanics that characterize osteoarthritic
gait [19]. However, there have been discrepancies in the analysis such
as subjects, methodology, and outcomes [20]. In addition, this change
could have diverse eects on the trunk, non-operated limb, and hip and
ankle joint in the operated limb [21]. They also provided the data using
various gait variables and magnitude of these changes remains variable
and unclear.
Therefore, this study was conducted to evaluate the change of
various gait variables with evidence based approach. We wanted to

Corresponding author at: Department of Orthopaedic Surgery, Seoul National University College of Medicine, Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-
do 463-707, South Korea.
E-mail addresses: smcos1@daum.net, smcos1@snu.ac.kr (Y.S. Lee).

http://dx.doi.org/10.1016/j.gaitpost.2017.05.023
Received 27 December 2016; Received in revised form 10 April 2017; Accepted 23 May 2017
0966-6362/ 2017 Elsevier B.V. All rights reserved.
S.H. Lee et al.
Fig. 1. PRISMA ow diagram.
know which variables show consistent changes and which variables
have controversy. Additionally, we also wanted to know whether type
of the osteotomy show dierent eect on the gait. Finally, pooled
analysis was the nal goal if it is possible. Our questions were as
follows: (1) How does HTO change basic gait variables? (2) How does
HTO change the gait variables in the knee joint?
2. Material and methods
2.1. Search strategy
A rigorous and systematic approach conforming to the preferred
reporting items for systematic review and meta-analysis (PRISMA)
guidelines was used [22]. In phase 1 of the PRISMA search process,
selected databases were searched in MEDLINE, EMBASE, and Cochrane
database (From the inception of the search database to September
2016). Using a Boolean strategy, all eld search terms included:
((((((((tibia) OR high) OR proximal) AND osteotomy))))) AND ((gait
analysis) OR gait). Citations in the included studies were screened and
we also checked unpublished or preparing articles with hand searches.
The bibliographies of the relevant articles were then cross-checked for
articles not identied in the search. Unrelated articles were also
prescreened. In phase 2, abstracts and titles were screened to assess
their relevance in relation to the study question. In phase 3, the full text
of the selected studies was reviewed to assess for the inclusion criteria
and methodological appropriateness with a predetermined question. In
phase 4, where in the studies underwent a systematic review process
and meta-analysis if appropriate.
2.2. Eligible criteria
Studies that met the following criteria were included: 1) in vivo
study of actual gait or motion analysis under weight-bearing conditions
before and after OW or CW HTO and 2) report of gait analysis on the
involved knee. Articles were excluded for the following reasons: 1)
other than HTO, 2) non-English article, 3) unavailable full text, 4) no
report of gait analysis, 5) pre- and postoperative data not comparable,
and 6) motion analysis under non-weight bearing conditions (Fig. 1).
2.3. Data extraction
The outcome of gait analysis was reported for trunk, hip, knee,
ankle, and other gait parameters. Therefore, we only focused on the
knee joint and basic parameters such as walking speed and stride
pattern. Two researchers (SH Lee and OS Lee) extracted following data:
58
Gait & Posture 57 (2017) 5768
level of evidence, study type, patient demographics, evaluation time,
system used for gait analysis, evaluated variables, comparison, pre-
operative gait analysis, postoperative gait analysis, and comments. The
extracted data were subsequently cross-checked for accuracy and any
disagreements were resolved by a consensus discussion between two
researchers; any disagreements were settled by the third review author
(YS Lee). In the meta-analysis, we used only available data that can be
conrmed from original article. We tried to obtain means and standard
deviation from tables, gures, and any values. However, it was
impossible to add some more data. We also sent an e-mail to only
seven authors because old articles did not provide an e-mail address.
However, we cant obtain any further data. Therefore, articles with few
samples or no detailed data were used only for the systematic review.
2.4. Quality assessment
The methodological quality of the randomized controlled trials
(RCT) was assessed using risk of bias (ROB), based on the Cochrane
handbook, with the following nine standard criteria: allocation se-
quence generation, allocation concealment, baseline outcome measure-
ment, baseline characteristics, incomplete outcome data, knowledge of
the allocated interventions, protection against contamination, selective
outcome reporting, and other ROB (dierent follow up period and
rehabilitation method). Each criteria was scored as Yes (low ROB),
No (high ROB), or Unclear.
The methodological quality of the cohort study or non-randomized
case-control study was assessed using a Newcastle-Ottawa assessment
scale. It consisted of three main domains (selection, comparability, and
outcome), with four categories in the selection domain, one category in
the comparability domain, and three categories in the outcome domain.
A study was awarded a maximum of one star for each item within the
selection and outcome domains. A maximum of two stars was given for
comparability. More stars mean low ROB.
2.5. Statistical analysis
Inter-reviewer agreement was assessed by calculation of a weighted
(kappa) for each phase of the abstract and full-text screening and
quality assessment agreement was also evaluated using an intra-class
correlation coecient (ICC) [23]. Statistical analysis was performed for
knee adduction moment and gait speed comparing pre-and postopera-
tive values using R version 3.3.1 (The R Foundation for Statistical
Computing). Subgroup analysis of the knee adduction moment was also
performed according to the type of osteotomy. To estimate the SMD
(standardized mean dierence), the mean and standard deviation
values were used. If mean and standard deviation data were not
provided in the studies, SMD was calculated from p-value and sample
size. We calculated standardized mean dierences equate to Hedgesg
eect size. All results were presented as forest plots. The 95%
condence interval (CI) was calculated for each eect size. The I2
statistic, which shows the percentage of total variation attributable to
the heterogeneity among studies, was calculated, and values of < 25%,
50%, and > 75% were interpreted as small, moderate, and high levels
of heterogeneity, respectively. A random eects model rather than a
xed eects model was used to calculate the eect size, because it was
assumed that studies within each subgroup did not share a common
eect size.
2.6. Grading of the quality of the evidence
In addition to describing the methodological quality of the included
studies, evidence was examined using the guidelines of the Grading of
Recommendations, Assessment, Development, and Evaluation (GRADE)
working group [24]. The GRADE system uses a sequential assessment of
evidence quality, followed by an assessment of the risk-benet balance
and a subsequent judgement on the strength of the recommendations.
 Table 1
Characteristics of the included studies.

Author Year Journal Level of Study type Case Control Evalution time System Variables Comparision
S.H. Lee et al.

evidence

Weidenhielm 1993 Scand J Rehab Med II RCT 23 CWHTO 36 UKA 12 months electronic walkway free walking speed, step frequency, CWHTO vs UKA
(M:F = 10:13) (M:F = 18:18) step length, maximal vertical
ground reaction force, single
stance phase, double stance phase
Birmingham 2009 Arthritis & Rheumatism II Prospective 128 24 month 8-camera motion capture system (Eagle peak magnitudes in the rst and OWHTO
cohort (Age: 47.48, M;F: EvaRT; Motion Analysis Corporation, second halves of stance and the (preop vs postop)
102;26) Santa Rosa, CA) synchronized with a area under the curve (impulse),
oormounted force platform gait speed, toe-out angle, lateral
(Advanced Mechanical Technology, trunk lean, walking speed
Watertown, MA)
Briem 2007 J Orthop Res. II Prospective 16 12 months Kinematic data: six-camera optoelectric muscle activity[medial and lateral OWHTO
cohort (Age: 52.2;49.3, motion analysis system (VICON, hamstrings (MH and LH), the (preop vs postop)
M;F: 10;6) Oxford Metrics, London, England) medial and lateral vasti (VM and
Kinetic data: Bertec VL), and the medial and lateral
(Worthington, OH) force platform gastrocnemius (MG and LG)],
maximal voluntary isometric
contraction(MVIC)
Marriott 2015 The American Journal of II Prospective 33 5 years 8-camera motion capture system knee moment, knee angle OWHTO
Sports Medicine cohort (40 years) (Motion Analysis Corp) synchronized + ACLR
with a single, oor-mounted force (preop vs postop)
platform (Advanced (surgical limb
Mechanical Technology Inc). nonsurgical)
Deie 2014 The Knee III RCS CWHTO OWHTO 12 months 3D motion analyzer gait speed, varus OWTHO
(M;F = 3;9, 57.8 (M;F = 3;6, 57.5 (Vicon 612, Vicon Motion Systems, moment, varus angle and lateral vs

59
years) years) Oxford, UK) with seven infrared thrust CWHTO
cameras (Vicon Motion Systems), oor
reaction force data were
measured using four force plates
(AMTI,Watertown, MA)
Ivarsson 1987 Clin Orthop Relat Res III RCS 14 Younger adults 12 months A foot-switch method walking speed, stride length, stride CWHTO
(M:F = 7:7, 60 given at Larsson lstride frequency, phases of the (preop vs postop
years) et al. (1980) stride vs other data)
Lind 2013 Knee Surg Sports Traumatol III PCS 11 (46 years) 9 males (47 years, 12 months A 10 camera Vicon MX3 Motion walking speed, stride length, OWHTO
Arthrosc non-operated Analysis System (Vicon, Oxford, UK) maximum knee exion(stance), (preop vs postop)
control) Two force plates embedded into a maximum knee extension(stance), (HTOnon-
10-m walkway (Kistler, Switzerland maximum knee exion(swing), operated control)
and AMTI, Watertown, MA, USA) maximum knee adduction(stance),
maximum exor moment,
maximum extensor moment,
maximum adductor moment(early
stance & late stance)
Mcclelland 2016 Bone Joint J III RCS 36 patients 6 years ten-metre walkway with two video minimum, maximum, mean OWTHO
(42 varus knee) cameras, and a force platform adductor momoent (preop vs postop)
(54.1 years, embedded in the oor (high adduction
M:F = 33:3) group
vs
low adduction
group)
Prodromos 1985 The Journal of Bone and III RCS 21 (25 varus 15 healthy adults 3.2 years peak adduction moment, knee HTO (CW or
Joint Surgery. gonarthrosis abduction moment, stride length, Maquet barrel-
knee) height, weight vault)
(preop vs postop)
(high adduction
(continued on next page)
Gait & Posture 57 (2017) 5768
S.H. Lee et al. Gait & Posture 57 (2017) 5768

RCT: randomized controlled trial, RCS: retrospective comparative study, PCS: prospective comparative study, CWHTO: closed wedge high tibial osteotomy, OWHTO: open wedge high tibial osteotomy, UKA: unicompartmental knee arthroplasty.
(preop vs postop)

(preop vs postop)

(preop vs postop)
vs low adduction

vs low adduction

vs low adduction
The evidence grades are divided into the following categories: (1) high,

(high adduction

(high adduction
Maquet barrel-
HTO (Maquet
which indicates that further research is unlikely to alter condence in

HTO (CW or
Comparision

barrel-vault)
the eect estimate; (2) moderate, which indicates that further research

CWHTO
group)

group)

group)
vault)
is likely to signicantly alter condence in the eect estimate, and may
change the estimate; (3) low, which indicates that further research is
legnth, walking velocity, foot angle likely to signicantly alter condence in the eect estimate, and may

moment vector tending to abduct

external adduction moment(Nm),

or adduct the knee-joint, ground-
change the estimate; and (4) very low, which indicates that any eect
peak adduction moment, stride

inertia, limb-segment weight

reaction force, limb-segment
estimate is uncertain. The strengths of the recommendations were
based on the quality of the evidence [25].

3. Results

walking speed
3.1. Search
Variables

Twelve articles were included in the nal analysis (Table 1)

force platform (Kistler Instrumente AG,
[6,1820,2631]. The reviewers showed substantial agreement in
selecting articles for inclusion at the abstract phase, with = 0.87
gait analysis system (Anima, Tokyo,

Winterthur, Switzerland) and two

(95% condence interval [CI], 0.760.88), at the full-text screening

videocameras (Hitachi FP-10)

phase, with = 0.86 (95% CI, 0.780.92), and at the quality assessment,
with = 0.78 (95% CI, 0.720.84). A total of 383 knees were evaluated.
There were 237 OWHTOs, 91 CWHTOs, and 52 Market barrel-vault
HTOs. There were 1 RCT, 3 prospective cohort studies [20,26,28], 3
prospective comparative studies (PCS) [19,31,32], and 5 retrospective
comparative studies (RCS) [6,18,27,29,30]. There were 4 level II
studies [20,26,28] and 8 level III studies [6,18,19,27,2931,32]. All
System

Japan)

studies included gait analysis and compared pre- and postoperative

values. One study compared CWHTO and unicompartmental knee
Evalution time

arthroplasty (UKA), and another study [18] compared CWHTO and

12 months

OWHTO. Five studies compared gait variables with those of healthy

8.9 years
6 years

controls [6,27,30,31,32]. One study compared operated limb gait

variables with those in the non-operated limb [19]. Regarding post-
operative rehabilitation, immobilization and range of motion (ROM)
10 healthy control
18 healthy adults

15 healthy adults

were only addressed. Three studies applied immobilization more than 4

weeks [29,32] and ve studies applied ROM exercise within 4 weeks
[1820,26,27].
Control

3.2. Quality

Quality assessment details were presented in Table 2A. One RCT

24 (55.5 years,
M;F = 11;13)
32 (68 years,
M:F = 9:23)

(M:F = 6:3)

was assessed using ROB, based on the Cochrane handbook. Five criteria
9 patients

were scored as Yes, 3 criteria were scored as Unclear, and 1

criterion was scored as No. Three cohort studies and 8 case-control
Case

studies were assessed using the Newcastle-Ottawa assessment scale. All

3 cohort studies showed a low ROB in all 3 domains. In the compar-
Study type

ability domain, all 3 studies were awarded 2 stars. In the 8 case-control

studies, 2 were awarded 4 stars, 1 was awarded 3 stars, and 5 were
RCS

PCS

PCS

awarded 2 stars of a possible 4 stars in the selection domain. In the

comparability domain, 1 study was awarded 2 stars and the others were
evidence

awarded 1 star. In the outcome domain, 2 studies were awarded 3 stars

Level of

and 6 studies were awarded 2 stars of a possible 3 stars.

III

III

III

3.3. GRADE evidence quality of each outcome

The Journal of Bone and
Clin Orthop Relat Res

GRADE evidence quality of each outcome is shown in Table 2B.

Four outcomes were separately evaluated. There were 3 of low quality
Clin. Biomech.
Joint Surgery.

and 1 of very low quality. Comparisons of the gait speed, knee

adduction moment, and lateral thrust showed low quality, and compar-
Journal

ison of the stride length showed very low quality.

3.4. Gait analysis

1998

1990

1992
Year
Table 1 (continued)

Gait analysis results including preoperative values, postoperative

Weidenhielm

values, and specic comments are presented in Table 3. Twelve articles

Author

analyzed gait after HTO using several variables and summarized in

Wang
Wada

Table 4. These variables are velocity [1820,27,30], stride length

[19,27,30], adduction moment [19,20,2831,32,33], lateral thrust

60
 S.H. Lee et al.

Table 2A
Quality assessment of the included studies.

Risk of Bias for RCTs

Author Year Level of Evidence 1 2 3 4 5 6 7 8 9

Weidenhielm 1993 II U U Y Y Y Y Y U N
Y, Yes; N, No; U, Unclear.

Newcastle-Ottawa assessment for cohort studies

Author Year Level of Evidence Selection Comparability Outcome

1) (**) 2) (*) 3) (**) 4) (*) 1) (**) 1) (**) 2) (*) 3) (**)

Birmingham 2009 II * * * * ** * * *
Briem 2007 II * * * * ** * * *

61
Marriott 2015 II * * * * ** * * *

Newcastle-Ottawa assessment for case-control studies

Author Year Level of Evidence Selection Comparability Outcome

1) (**) 2) (*) 3) (**) 4) (*) 1) (**) 1) (**) 2) (*) 3) (**)

Deie 2014 III * * * * ** * * *

Ivarsson 1987 III * * * * * *
Lind 2013 III * * * * *
Mcclelland 2016 III * * * * * * * *
Prodromos 1985 III * * * * *
Wada 1998 III * * * * *
Wang 1990 III * * * * *
Weidenhielm 1992 III * * * * *
Gait & Posture 57 (2017) 5768
S.H. Lee et al.
Table 2B
GRADE evidence quality for each outcome.
N Design Limitation Inconsistency
(study)
Gait speed
5 Prospective cohort No Yes(-1)
study 1
RCT 1
RCS 2
PCS 1
Stride length
4 RCT 1 No YES(-2)
RCS 2
PCS 1
Knee adduction
moment
8 Prospective cohort No No
study 2
RCS 3
PCS 3
Lateral thrust
2 Prospective cohort No No
study 1
RCS 1
RCS: Retrospective Comparative Study, PCS: Prospective Comparative Study, RCT: Randomized Controlled Trial.
[18,20], muscle activation [26], cadence [27], knee exion moment
[19,28], toe foot angle [20,30], vertical ground force and single and
double stance phase, ankle inversion moment [31], relationship
between change in knee adduction moment, and changes in mechanical
axis angle [20,30]. Gait speed, adduction moment, and lateral thrust
showed consistent change in most articles. Stride length was evaluated
in four articles and there was controversy. Other variables have been
evaluated in just one or two articles. Pooled analysis was possible in
gait speed and adduction moment.
3.5. Gait speed
Gait speed was addressed in 2 level II [20] and 4 level III
[18,19,27,30] studies. The pooled analysis of gait speed was performed
using 5 articles [1820,27] and presented in Fig. 2A (standardized
mean dierence [SMD] 0.764, 95% CI 0.349 to 1.178, with high
heterogeneity I2 = 72.7%, p = 0.0026). Among 6 studies, two level II
studies showed an increase in gait speed, but without statistical
signicance [20]. Other 4 studies reported that last follow-up walking
speed increased compared to the preoperative value, with statistical
signicance.
Birmingham et al. [20] reported that gait speed was increased from
1.10 0.17 m/s to 1.16 0.16 m/s without signicance (p = 0.06).
Another level II study by Weidenhielm et al. [32], preoperative walking
speed was 1.03 0.19 m/s; this value increased to 1.09 0.15 m/s,
but the increase was not statistically signicant. The authors commen-
ted that this increase was due mainly to an increase in step length by
the uninvolved leg. The other 4 level III studies reported a similar
increase in gait speed after HTO, with statistical signicance. Deie et al.
[18] reported that gait speed was increased 0.90 0.16 to
1.10 0.16 m/s in CWHTO group and 0.90 0.16 to
1.10 0.16 m/s in OWHTO at postoperative 1 year. In the study by
Ivarsson et al. [27], maximal and mean values of gait speed were
increased 1.33 0.39 to 1.45 0.45 m/s and 0.85 0.26 to
0.97 0.33 m/s after CWHTO, with statistical signicance, but these
values were lower than those in normal controls. In the study by Lind
et al. [19], self-selected walking speed increased signicantly from
1.22 0.13 to 1.43 0.18 m/s in OWTHO group and postoperative
walking speed was not dierent from normal control group. Wada et al.
[30] compared gait speed between high knee adduction moment and
Gait & Posture 57 (2017) 5768
Indirectness Publication Bias N Summary Quality
No No 229 5 studies reported gait speed decrease. Among them, 1 Low
study showed an inversed of the gait speed without
statistically signicance
No No 80 Among 4 studies, only 1 study reported that stride Very Low
length increase with statistically signicance.
No No 294 All of 8 studies reported that adduction moment Low
decrease with statistically signicance.
No No 149 2 studies reported reduced lateral thrust with Low
statistically signicance
low knee adduction moment groups and they reported that gait speed
was increased in both groups; these values were similar to those in
normal control.
3.6. Stride length
Stride length was addressed in 1 level II study and 3 level III studies
[19,27,30]. However, it was impossible to perform pooled analysis
because the data were limited and it was comparable in only two
studies. In general, stride length was increased or was similar to the
preoperative value or normal control value. In the level II study by
Weidenhielm et al. [32], the value increased from 0.61 0.08 m to
0.62 0.09 m, but this was not a statistically signicant dierence.
Ivarsson et al. [27] reported that stride length was decreased at
maximal speed with statistical signicance, but was not dierent at
usual speed. They also stated that stride length was correlated with
muscle torque, especially isokinetic hamstring torque at an angular
velocity of 30/s. Lind et al. [19] reported a statistically signicant
increase in stride length from 1.22 m/s to 1.48 m/s. Wada et al. [30]
reported that stride length in the high knee adduction group was
smaller compared to that in controls, but was similar at the last follow-
up. In the low knee adduction group, the value was not dierent
compared with that in a control group at preoperative evaluation and
last follow-up.
3.7. Knee adduction moment
Knee adduction moment was addressed in 2 level II [20,28] and 6
level III [6,19,2931,32] studies. All studies reported that last follow-up
knee adduction moment was decreased compared to the preoperative
value. In 2 level II [20,28] studies, knee adduction moment showed a
statistically signicant dierence between preoperative and last follow-
up values. Pooled analysis was performed using 7 articles. Knee
Adduction moment was decreased (standardized mean dierence
[SMD] 1.534, 95% CI 1.976 to 1.092, with high heterogeneity
I2 = 81.7%, p < 0.0001) (Fig. 2B). In the subgroup analysis, knee
adduction moment showed a signicant decrease in both CWHTO (SMD
0.886, 95% CI 1.181 to 0.592, I2 = 0%, p = 0.9169) and
OWHTO groups (SMD 2.039, 95% CI 2.568 to 1.510,
I2 = 75.6%, p = 0.0026) (Fig. 2C). In, the meta-regression analysis
62
 Table 3
Change of the gait pattern after HTO.

Author Year Comparision Gait (preoperative) Gait (postoperative) Comment

S.H. Lee et al.

Weidenhielm 1993 CWHTO vs UKA Walking speed(m/s):1.03 0.19
Step freqeuncy(steps/s): 1.68 0.2
Step length(m): 0.61 0.08
Single stance phase involved/
uninvolved:0.97 0.04
Double stance phase(%, gait cycle): 15.3 2.3
Max. vertical groung reaction force-involved/
uninvolved: 0.96 0.08
Stance phasee exion(): 12 5.7
Swing phase exion(): 53 9
Birmingham 2009 OWHTO Knee adduction movement
(preop vs postop) -First peak, %BW Ht: 2.99 0.92
-Second peak, %BW Ht: 2.37 1.08
-Area under the curve, % BW Ht s:
1.45 0.49
Speed: 1.10 0.17 m/s
Toe-out angle: 12.00 5.77
Lateral trunk lean: 3.45 2.97
Walking speed(m/s):1.09 0.15
Step freqeuncy(steps/s): 1.75 0.14
Step length(m): 0.62 0.09
Single stance phase-involved/uninvolved:
0.97 0.04
Double stance phase(%, gait cycle): 14.0 1.5
Max. vertical groung reaction force-involved/
uninvolved: 0.97 0.04
Stance phasee exion (): 12 3.6
Swing phase exion (): 55 8
Knee adduction movement
-First peak, %BW Ht: 1.62 0.69
-Second peak, %BW Ht: 1.30 0.78
-Area under the curve, % BW Ht s:
0.77 0.36
Speed: 1.16 0.16 m/s
Toe-out angle: 13.20 5.40
Lateral trunk lean: 1.96 2.07
1. Walking speed increase numericlly and this
increase was due mainly to an increase in step
length of the uninvolved leg.
1. Despite a slight increase in speed and a
decrease in lateral trunk lean toward the stance
extremity (both reect a more normal gait
pattern and would increase medial joint load),
there was a large reduction in all measures of the
external knee adduction moment
postoperatively. Interestingly, there was also a
small increase in toe-out angle that would serve
to further reduce the knee adduction moment. 2.
Importantly, unlike alignment, we observed an
unexpected increase in the knee adduction
moment from 6 to 24 months postoperatively.
The increase was not observed on the opposite
extremity, and therefore is not likely an overall
response to the small increase in gait speed

63
observed over the same postoperative time
period. The magnitude of the increase in
postoperative knee adduction moments from 6 to
24 months was small (13%),
and its value at 2 years postoperatively was still
far less than those observed preoperatively or on
the opposite extremity (55% and 65%,
respectively). However, we believe that these
relatively early postoperative increases in the
knee adduction moment are of potential concern
and may be a precursor to poorer longer-term
outcomes. 3. Changes in the knee adduction
moment without concomitant changes in
mechanical axis angle are consistent with
previous reports of the low to moderate
correlation between these measures.
Briem 2007 OWHTO Presented in the postoperative data with changed Relationship between degree of deviation from 1. Change in VMMH co-contraction after surgery
(preop vs postop) values desired MAA and diered depending on the degree of frontal plane
-the amount of co-contraction of the VMMH alignment. 2. These changes, in turn, were
(r2 = 0.654, p < 0.001) positively correlated with pre- to postoperative
-the VLLG (r2 = 0.394, p = 0.009) muscle groups changes in the AMic and VLLG co-contraction
-knee adduction moment at initial contact (AMic) indices.
(r2 = 0.44, p = 0.048)
Correlation
-between the degree of deviation from the desired
MAA and the changes seen in VMMH co-
contraction (r2 = 0.512, p = 0.002).
-between the amount of VMMH cocontraction and
AMic (r2 = 0.431, p = 0.006)
(continued on next page)
Gait & Posture 57 (2017) 5768
 Table 3 (continued)

Author Year Comparision Gait (preoperative) Gait (postoperative) Comment

S.H. Lee et al.

-between the changes in VMMH co-contraction and

the changes in AMic (r2 = 0.443, p = 0.005),
VLLG co-contraction (r2 = 0.311, p = 0.031)
Marriott 2015 OWHTO + ACLR Peak External Knee Moments Peak External Knee Moments 1. Knee adduction moment: sugical knee
(preop vs postop) Adduction: 2.94 0.67 Adduction: 1.46 0.60 decreased (%BW H, 1.49; 95% CI, 1.75 to
(surgical limb Flexion: 1.97 1.41 Flexion: 1.30 1.06 1.22)
nonsurgical) Extension: 2.51 1.27 Extension: 2.96 1.07
Internal rotation: 1.23 0.31 Internal rotation: 0.71 0.25
External rotation: 0.05 0.06 External rotation: 0.06 0.06
Peak Knee Angle Peak Knee Angle
Varus: 5.23 4.69 Varus: 2.56 4.44
Flexion: 17.00 6.76 Flexion: 13.20 5.41
Extension: 2.51 5.50 Extension: 0.36 5.87
Internal rotation: 1.69 10.90 Internal rotation: 8.76 9.42
External rotation: 9.63 11.40 External rotation: 15.50 10.30
Deie 2014 OWTHO Gait speed(m/s) Gait speed(m/s) 1. Gait speed, maximum varus angle gait,
vs CW: 0.90 0.16, OW: 0.83 0.14 CW: 1.10 0.16, OW:1.10 0.14 maximum varus moment were improved in both
CWHTO Maximum varus angle gait () Maximum varus angle gait () group 2. OW reduced knee varus moment and
CW: 9.5 8.3, OW: 7.2 3.2 CW: 0.3 6.2, OW:0.0 2.7 lateral thrust, whereas CW had little eect on
Lateral thrust () Lateral thrust () reducing lateral thrust.
CW: 1.96 1.5, OW: 1.11 0.6 CW: 1.27 1.2, OW: 0.60 0.2
Maximum varus moment for the knee joint Maximum varus moment for the knee joint
(Nm/kg) (Nm/kg)
CW: 0.73 0.22, OW: 0.67 0.12 CW: 0.48 0.23, OW 0.37 0.11
Ivarsson 1987 CWHTO Velocity(m/s) Velocity(m/s) 1. Velocity: preop & postop maximal & mean
(preop vs postop vs maximal preop velocity: 1.33 0.39 maximal/mean preop velocity: 1.45 0.45/ speed were lower than healthy (2.40 0.47,

64
other data) mean preop velocity: 0.85 0.26 0.97 0.33 1.28 0.18), 2. Positive correlations: between
Stride length and cadence stride length and muscle torque in the thigh.
at a constant maximal velocity: decreased in stride
length of 0.04 0.05m
at a constant ordinary velocity: no signicant
dierence
Muscular torque and gait
positive correlations between the muscle torque of
the quadriceps and hamstrings muscles on the
aected side and the maximal velocity.
stride length was correlated to muscle torque
(strongest correlation: isokinetic hamstrings torque
at an angular velocity of 30/s)
Lind 2013 OWHTO Walking speed: 1.22 m/s Walking speed: 1.43 m/s(not signicantly diernet 1. Walking speed, stride length, knee
(preop vs postop) Stride length: 1.37 m from control group) extension & exion during swing phase, peak
(HTOnon-operated Maximum knee exion(stance): 11.0(8.7) Stride length: 1.48m(not signicantly diernet knee exion during stance, peak knee exor
control) Maximum knee extension(stance): 2.2(6.3) from control group) moment were not signicantly dierent from
Maximum knee exion(sweing):55.5(4.8) Maximum knee exion(stance):19.5(5.4) control group, 2. Knee adduction moment-preop,
Maximum knee adduction(stance): 13.5(4.1) Maximum knee extension(stance): 2.6(5.9) no dierence but postop, signicantly reduced
Maximum exor moment: 1.5(1.5) Maximum knee exion(swing): 58.4(4.8) knee adduction moment
Maximem extensor moment: 2.1(1.2) Maximum knee adduction(stance): 5.4(3.1)
Maximum adductor moment(early stance): Maximum exor moment: 3.6(1.5)
3.9(0.7) Maximem extensor moment: 1.5(1.2)
Maximem adductor moment(late stance): 3.5(1.0) Maximum adductor moment(early stance):
2.7(0.9)
Maximem adductor moment(late stance): 1.9(0.8)
Mcclelland 2016 OWTHO Peak adduction moment(%, 95% CI)) Peak adduction moment(%) 1. Short to medium term result(210 year)
(preop vs postop) -total mean: 3.98 0.38 -total mean: 2.71 0.49 -adductor moment decreased(high adductor
(high adduction -high adductor group mean(> 4% body -high adductor group mean: 2.82 0.71 (p < 0.008), low adductor(p = 0.007)
(continued on next page)
Gait & Posture 57 (2017) 5768
 Table 3 (continued)

Author Year Comparision Gait (preoperative) Gait (postoperative) Comment

S.H. Lee et al.

group weight Height): 4.91 0.4 -low adductor group mean: 2.60 0.69 -greater degree of angular correction was seen in
vs -low adductor group mean(< 4% body the high adductor group (p = 0.019) compared
low adduction weight Height): 3.06 0.37 with the low adductor group.
group) -after the correction, the peak adductor moment
when walking at 1 m/s had reduced
(p < 0.001). & mean pre-operative adductor
moment was improved (p < 0.001)
Prodromos 1985 HTO (CW or Maquet Peak knee adductiom moment during walking was Peak adduction moment during walk The adduction moment was reduced in both
barrel-vault) higher than normal. -high adduction moment group: reduced to groups after HTO, however the average
(preop vs postop) Stride length statistically normal value postoperative adduction moment in the low
(high adduction vs -high adduction moment group: not dierent from -low adductiom moment group: signicantly lower adduction moment group was still signicantly
low adduction normal than noraml control group lower than high adduction group.
group) -low adduction moment group: signicantly below patients with a higher peak adduction moment
normal preoperatively ultimately had greater varus
deformity.
Wada 1998 HTO (Maquet barrel- (high adductionlow adduction) Peak adduction moment 1. Change in adduction moment after surgery
vault) Peak adduction moment: 5.7% 1.4% -high adduction moment group:higher without was not statistically signicant, 2. Stride length,
(preop vs postop) 4.0% 0.5% statistically signicance walking velocity
(high adduction vs Stride length: 0.76 0.13 m 0.85 0.13 m -low adduction moment group: lower at 6 months -high adduction moment group: shorter than
low adduction walking velocity: 0.64 0.18m/s but gradually increased after 6 month. remained control at preop but similar at 1 year postop
group) 0.69 0.16m/s with the range of control value until 6-year f/u -low adduction moment group: similar to control
foot angle: 12 10 10 8 -stride length: reached a plateau at 3 years in both group at preop, but lower at 6 months, reached a
group plateau at 3 year postop
-walking velocity: gradually increase 3. The peak adduction moment of the knee for
Foot angle the whole group signicantly correlated with
-high adduction moment group: increase to alignment and foot angle(r2 = 0.18) before and

65
17 14 at 6 months but decrease 6 years after surgery but did not correlate with
-low adduction moment group: similar to high stride length and walking velocity.
adduction moment group
Wang 1990 HTO (CW or Maquet The peak inversion moment at the ankle during There was a signicant reduction of peak inversion 1. The adduction moment at the knee can be
barrel-vault) walking was signicantly higher in the high moment at the ankle during walking one year reduced by increasing the outward rotation of
(preop vs postop) adduction-moment group(p < 0.005) postoperatively in both groups. the foot.
(high adduction vs
low adduction
group)
Weidenhielm 1992 CWHTO Knee Knee 1. Before surgery, there wes a signicantly
(preop vs postop) -peak adduction: 78(44) -peak adduction: 26(34) increased adduction moment in knee joints
-midstance: 62(25) -midstance: 16(16) compared to the normal controls.
-area: 37(18) -area: 12(7) 2. After surgery, the adduction moment was
reduced to subnormal levels in the knee but the
ankle joint were unaected both by the knee
deformity and by the corrective surgery.

CWHTO: closed wedge high tibial osteotomy, OWHTO: open wedge high tibial osteotomy, UKA: unicompartmental knee arthroplasty, Bt: body weight, Ht: height.
Gait & Posture 57 (2017) 5768
S.H. Lee et al. Gait & Posture 57 (2017) 5768

Fig. 2. Pooled analysis of the gait speed (A); Pooled analysis of the knee adduction moment (B); Subgroup analysis of the knee adduction moment according to osteotomy type (C); (TE:
modied standardized mean dierence, seTE: standard deviation of modied standardized mean dierence).

for identifying the cause of high heterogeneity, patients age was one of
the main factor that aected high heterogeneity (R2 = 32.93%).
In the level II study, Birmingham et al. [20] reported that knee
adduction movement decreased signicantly from 2.99 0.92 to
1.62 0.69 (% Body weight height) at rst peak of gait. Another
level II study by Marriott et al. [28], peak adduction moment decreased
from 2.94 0.67 to 1.46 0.60 (% Body weight height) with
statistical signicance. In the study by Lind et al. [19], maximum
adductor moment in early stance increased from 3.9 0.7 to
2.7 0.9 (% Body weight height) with statistical signicance.
Mcclelland et al. [28] reported that mean adduction moment decreased
from 3.98 0.38 to 2.71 0.49 Nm/kg. In the study by Wada et al.
[30], peak adduction moment decreased from 5.7 1.4% to
4.6 0.6% in the high adduction moment group and from
4.0 0.5% to 2.7 1.2% in the low adduction moment group. In
the study by Weidenhielm et al. [32], knee peak adduction moment
decreased from 78 44 Nm to 26 34 Nm. Prodromos et al. [6] and
Wang et al. [30] also reported a decreased adduction moment, but
detailed data were not reported.
3.8. Lateral thrust
Lateral thrust was addressed in 1 level II [20] and the other level III
[18] studies. In the 1 level II study, Birmingham et al. [20] reported
that lateral thrust decrease from 3.45 2.97 to 1.96 2.07
(p < 0.01). The other level III study by Deie et al. [18], the lateral

66
S.H. Lee et al. Gait & Posture 57 (2017) 5768

Table 4
Summary of gait analysis of each variable.

Variable Included study Summary

Velocity 6 Increase of gait speed (2 studies [Birmingham, Weidenhielm (1993)] without statistical signicance and 4 studies
[Deie, Ivarsson, Lind, Wada] with statistical signicance)
Stride length 4 Increase (1 study [Lind] with statistical signicance and 1 study [Weidenhielm (1993)] without statistical
signicance), Decrease (1 study [Ivarsson]), and Similar to normal control (1 study [Wada])
Adduction moment 8 Decrease (5 studies [Birmingham, Marriot, Lind, Mcclelland, and Weidenhielm (1992)] with statistical
signicance, 1 study [Wada] without statistical signicance and 2 studies [Wang, Prodromos] without detailed
data)
Lateral thrust 2 Decrease (2 studies [Brimingham, Deie] with statistical signicance)
Muscle activation 1 Co-contraction of vastus medialis and medial hamstring diered depending on the degree of frontal plane
alignment [Briem]
Cadence 1 For any given velocity, higher cadence was reported without detailed data [Ivarsson]
Knee exion moment 2 Increase (1 study [Lind] with statistical signicance), Decrease (1 study [Marriot] with statistical signicance)
Toe foot angle 2 Increase (1 study [Brimingham] with statistical signicance and other 1 study [Wada] without detailed data).
Vertical ground force 1 Similar result [Weidenhielm (1993)]
Single and double stance phase 1 Similar in single stance phase but decreased in double stance phase with statistical signicance [Weidenhielm
(1993)]
Ankle inversion moment 1 Reduction (1 study [Wang] with statistical signicance)
Relationship between change in knee 2 Low to moderate correlation (1 study [Birmingham]), Signicant correlation (1 study [Wada])
adduction
moment and changes in mechanical
axis angle

thrusts in the CW- and OWHTO groups decreased from 1.96 1.5
and 1.11 0.6 to 1.27 1.2 and 0.60 0.2 with statistical
signicances, respectively. They also reported that OW reduced knee
varus moment and lateral thrust, whereas CW had little eect on
reducing lateral thrust.
3.9. Other relevant ndings
Regarding muscle activation, in the level II study by Briem et al.
[26], reported that change in co-contraction of the vastus medialis and
medial hamstring (VMMH) after surgery diered depending on the
degree of frontal plane alignment. These changes were positively
correlated with pre- to postoperative changes in the adduction moment
and co-contraction of the vastus lateralis and lateral gastrocnemius
VLLG co-contraction indices. The relationship between change in knee
adduction moment and changes in mechanical axis angle was addressed
in 1 level II [20] and the other level III [30] studies. In the level II study
by Birmingham et al. [20], change in the knee adduction moment
showed low to moderate correlation, similar to that in other studies.
However, in the level III study by Wada et al. [30], the peak adduction
moment of the knee was signicantly correlated with alignment in both
high and low knee adduction moment groups. They also reported that
the adduction moment at the knee can be reduced by increasing the
outward rotation of the foot.
4. Discussion
The principal ndings of this systematic review and meta-analysis
were as follows: (1) Walking speed increased and stride length was
increased or similar after HTO compared to the preoperative value in
basic gait variables. (2) Knee adduction moment and lateral thrust were
decreased after HTO compared to the preoperative knee joint gait
variables. Some studies reported improvement in biomechanical factors
that aggravate osteoarthritis. However, general consensus has not been
reached on the eect of HTO in terms of biomechanical factors
compared to that for biomechanical risk factors in the pathogenesis of
osteoarthritis. Biomechanical factors after HTO has been studied under
static loads and contradictory results of the relationship between static
limb alignment and dynamic shift of loading have been reported
[7,3236]. In contrast, knee adduction moment during gait is generally
accepted as a potential risk factor for the progression of osteoarthritis
by increasing the dynamic loading [37,38].
Gait speed increased in all articles with or without statistical
signicances and pooled analysis showed an increased gait speed with
statistical signicance. However, most studies did not address how this
change can occur. Only one study assumed that this increase was due
mainly to an increase in step length of the uninvolved leg. It can be
assumed that the reduced pain could enable the patient to increase gait
speed and maximal stride length. In addition, the reduced pain could
improve muscle torque of the quadriceps and hamstring. However, the
reason why it may dier from some articles would be that time points of
gait analysis were dierent in each paper, and gait speed and stride
length could show a dierence between CW and OW.
All studies reported that last follow-up knee adduction moment was
decreased compared to the preoperative value and pooled analysis also
showed a decreased adduction moment with statistical signicance.
This eect was more evident in OWHTO than in CWHTO, according to
the pooled analysis. After HTO, mechanical alignment is shifted
laterally and most important and prominent characteristic of this
valgus producing HTO is to change the alignment from varus to valgus.
The large adduction moment may in part be due to anatomical
alterations in the varus aligned knee [1]. Therefore, these consistent
results of our analysis could be originated from corresponding char-
acteristics between HTO and adduction moment.
Varus thrust visualized during walking is also associated with a
greater risk of medial knee osteoarthritis [2]. Most studies reported that
varus thrust was decreased after HTO. One recent study reported that
the eect was more prominent in OWHTO than in CWHTO [18]. Lateral
thrust also showed a dierence between after CWHTO and OWHTO
[18]. According to the nature of these two surgical procedures, changes
in varus and valgus laxity of the knee joint were dierent between
CWHTO and OWHTO [39]. Joint instability before CWHTO sustained
after the surgery. However, OWHTO decreased medial and lateral laxity
slightly compared to before surgery.
This systematic review included 1 RCT, 3 prospective cohort
studies, 1 PCS, and 7 RCSs. There were 4 level II and 8 level III studies.
These relatively low-quality studies led to high heterogeneity of the
meta-analysis. We reduced heterogeneity by performing subgroup
analysis according to the type of osteotomy. Meta-regression analysis
was also performed in the gait speed and adduction moment using age,
follow-up period, rehabilitation protocol to reduce heterogeneity. Age
was one of main factor that cause high heterogeneity in the adduction
moment. However, we could not nd any factor in the gait speed. We
also strived to mitigate low quality in our review process by weighting

67
S.H. Lee et al.
the results of each individual article based on the level of evidence.
Results of a high-level study were reported rst. Results of a low-level
study followed, and were compared with those of the high-level study.
These results also aected the quality of the GRADE evidence for each
outcome. In general, most outcomes showed low quality. There were
several additional limitations in this systematic review. We could not
conrm the relationship between gait variables and clinical relevance
because no study reported about this relationship. It would be necessary
to evaluate the direct relationship between improved gait variables and
clinical outcomes. Second, most articles on CWHTO were published
long ago. The results could be outdated and the evaluation methods
may have changed.
5. Conclusion
Based on our systematic review and meta-analysis, walking speed
and stride length increased after HTO. Knee adduction moment and
lateral thrust decreased after HTO compared to the preoperative values
of gait variables in the knee joint. Other variables remained contro-
versial, although they are relatively well known in the pathogenesis of
osteoarthritis.
Conict of interest statement
The authors have no conicts of interest to declare.
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