J Orthop Sci (2007) 12:214–218
DOI 10.1007/s00776-007-1112-7
Original article
Femoral shaft bowing influences the correction angle for
high tibial osteotomy
Ryuji Nagamine1, Sanshiro Inoue2, Hiromasa Miura2, Shuichi Matsuda2, and Yukihide Iwamoto2
1
Department of Orthopaedic Surgery, Yoshizuka Hayashi Hospital, 7-6-29 Yoshizuka, Hakata-ku, Fukuoka, Fukuoka 812-0041, Japan
2
Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Abstract
Background. The optimal femorotibial angle (FTA) after
high tibial osteotomy (HTO) is still controversial. Our hy-
pothesis was that FTA itself may not be reliable because FTA
cannot represent the accurate alignment of the whole lower
extremity.
Methods. Non-weight-bearing radiographs of the lower ex-
tremities were taken in 100 Japanese subjects with medial
osteoarthritic knees, and seven anatomic parameters were as-
sessed. The correction angle by FTA was calculated so that
the postoperative FTA was set at 166° (14° valgus). Another
correction angle was calculated so that the mechanical axis
passed through the lateral one-fourth of the tibial articular
surface after HTO. After the correlation between two correc-
tion angles was assessed, influences of anatomic parameters
on the discrepancy between two correction angles were
assessed.
Results. There was a high correlation between two correction
angles (R2 = 0.777, P < 0.001). The mechanical axis passed
through the lateral one-fourth of the tibial articular surface
when the postoperative FTA was set at 166° in 80% of sub-
jects. However, discrepancy between the two correction an-
gles was 3° or larger in 20% of subjects. Femoral shaft bowing
and tibial shaft bowing significantly influenced the correction
angles. Even though FTA was the same, the femoral head
shifted medially in cases with lateral bowing of the femoral
shaft, and the correction angle by FTA should be set larger.
On the other hand, the correction angle by FTA can be set
smaller in knees with medial bowing of the femoral shaft.
Tibial shaft bowing also influences the correction angle by
FTA.
Conclusions. The correction angle by FTA for HTO should
be calculated taking femoral and/or tibial shaft bowing in the
frontal plane into account.
Offprint requests to: R. Nagamine
Received: September 4, 2006 / Accepted: January 10, 2007
Introduction
High tibial osteotomy (HTO) is one of the surgical
treatments for medial osteoarthritis of the knee. The
knee alignment before and after HTO is mainly evalu-
ated by the femorotibial angle (FTA).1–13 Long-term
follow up studies had shown the optimal postoperative
FTA to be between 164° and 170° (16° valgus and 10°
valgus) in Japan,1,2 and this angle was between 164° and
175° (16° valgus and 5° valgus) in Western countries.3–6
Some studies had shown no relationship between the
postoperative FTA and clinical outcome.7–9 The optimal
FTA after HTO is still obscure. It has never been ana-
lyzed why the optimal FTA after HTO was different
among the studies. Our hypothesis was that FTA itself
may not be reliable, because FTA does not represent
the accurate alignment of the whole lower extremity,
and anatomic variations of the femur and the tibia in
the frontal plane are not taken into account. The me-
chanical axis can be used to calculate the other correc-
tion angle for HTO.14 The correction angle by the
mechanical axis is not influenced by anatomic varia-
tions; therefore, it may be more reliable than the cor-
rection angle by FTA. The purpose of this study is to
clarify whether FTA is reliable for evaluation of the
alignment of the lower extremity in all subjects and
whether anatomic variations in the frontal plane influ-
ence the correction angle by FTA.
Materials and methods
This study consisted of 100 lower extremities in 100
Japanese subjects with medial osteoarthritic knees. In-
terlocking closed-wedge HTO was performed in all sub-
jects.14 There were 22 men and 78 women, and their
mean age was 68 years old (range, 50–82 years). On ra-
diography in the standing position, the medial femoro-
tibial joint space had disappeared in 25 cases and was
 R. Nagamine et al.: Correction angle for HTO
A B
Fig. 1. Orthoradiography was taken in 100 lower extremities
of 100 cases in that HTO was performed. Two cases with lat-
eral (A) and medial (B) bowing of the femoral shafts are
shown
less than 3 mm in 52 cases. It was slightly decreased in
23 cases. According to the rules of the ethics committee
in our hospitals, all patients were informed that data
from the study would be submitted for publication, and
they gave their consent. Before HTO, all patients re-
ceived the standardized non-weight-bearing radiographs
of their lower extremities, known as orthoradiography,
which used three successive exposures centered over
the hip, knee, and ankle, with tube-to-film distance of
2 m (Fig. 1).14,15 Care was taken to place the lower ex-
tremities in a neutral position so that the patella faced
anteriorly. No patient had flexion contracture of more
than 10°. No patient had patellar subluxation/disloca-
tion. On orthoradiography, central lines of proximal
and distal diaphysis of the femur and the tibia were
drawn.15 Seven anatomic parameters were measured,
these being the femoral angle (FA), the lateral bowing
angle of the femoral shaft (BFS), the tibial angle (TA),
the lateral bowing angle of the tibial shaft (BTS), the
tibial plateau shift angle (TPSA), FTA, and the percen-
tile of the mechanical axis on the tibial plateau (%MA)
(Fig. 2).15 FA is the lateral angle between the central
line of the distal diaphysis of the femur and the tangent
of the distal femoral condyles. BFS is the angle between
the central lines of the distal and proximal diaphysis of
215
Cs Cp
TA
TPSA
BFS
midpoint
BTS
FA
A B
Fig. 2. Schematics of the parameters are shown: FA, Femoral
angle; BFS, lateral bowing angle of the femoral shaft (A); Cp,
central point of the tibial articular surface; Cs, central line of
the proximal tibial shaft; midpoint, point located by bisecting
the proximal-to-distal length of the tibia; TA, tibial angle;
TPSA, tibial plateau shift angle; BTS, lateral bowing angle of
the tibial shaft (B)
the femur. TA is the lateral angle between the central
line of the proximal diaphysis of the tibia and the line
between the medial and lateral tibial plateaus. BTS is
the angle between the central lines of the distal and
proximal diaphysis of the tibia. TPSA is the angle be-
tween the central line of the proximal diaphysis of the
tibia and the line from the central point of the tibial
plateau (articular surface) to the midpoint of the tibia.
TPSA demonstrates the medial deviation of the central
point of the tibial articular surface from the central line
of the proximal diaphysis of the tibia. FTA is the lateral
angle between the central line of the distal diaphysis of
the femur and the central line of the proximal diaphysis
of the tibia. The mechanical axis was drawn from the
central point of the femoral head to the central point of
the articular surface of the talus. %MA was 0% when
the mechanical axis passed through the medial edge
of the tibial plateau and was 100% when the mechanical
axis passed through the lateral edge.
When the correction angle by %MA was calculated
on the orthoradiograph, postoperative alignment was
achieved so that %MA was 75% (lateral one-fourth of
the tibial articular surface).11,14 The method of the cal-
culation is shown in Fig. 3.14 First, the preoperative
mechanical axis is drawn. The broken line shows an
osteotomy line parallel to the tibial articular surface
(Fig. 3A). The postoperative mechanical axis is drawn
so that %MA is 75% (Fig. 3B). A line is drawn from
the medial edge of the osteotomy line to the center of
the talus, defined as line A. Line B, which has the same
length as line A, is drawn from the medial edge of the
osteotomy line to the postoperative mechanical axis
216
1/4
Line B
Line A
A B C %MA was greater than that by FTA by 3° or larger in
Fig. 3. Schematic of correction angle by %MA (percentile of
the mechanical axis on the tibial plateau) is shown. The
broken line shows the osteotomy line (A). The postoperative
mechanical axis is drawn so that %MA is 75% (B). The angle
between line A and line B shows the correction angle by
%MA (C)
(Fig. 3C). The angle between line A and line B is to be
the correction angle by %MA. While the correction
angle by FTA was calculated, the postoperative FTA
was set at 166° (14° valgus), because it has been re-
ported that FTA of 164° to 168° (16° to 12° valgus)
should be attained to ensure favorable long-term results
in HTO in Japan.1 If the discrepancy between two
correction angles was larger or equal to 3°, the cor-
rection angles were considered to be unreliable in this
study.1,16
The correlation between two correction angles was
assessed. Next, the correlation between each anatomic
parameter and the discrepancy between two correction
angles was assessed. Statistical analysis was done using
the correlation analysis, with a probability of less than
0.05 being significant.
Results
FA was 81.9° ± 2.1° (mean ± standard deviation) (range,
77° to 87°); BFS was 2.2° ± 3.2° (−3.5° to 16°); TA was
97.2° ± 3.4° (89° to 106°); BTS was −0.1° ± 2.0° (−6° to
6°); and TPSA was 2.1° ± 1.5° (0° to 7°). The preopera-
tive FTA was 180.8° (0.8° varus) ± 4.8° (171° to 196°)
(9° valgus to 16° varus) and the preoperative %MA was
19.6% ± 15.6% (−25.4% to 47%). The correction angle
by FTA and that by %MA were calculated, and they
were 14.8° ± 4.8° (5° to 30°) and 15.1° ± 4.7° (7.5° to
28°), respectively. The results showed that the charac-
teristics of Japanese patients with medial osteoarthritic
knees were the proximal tibia vara with medial shift of
R. Nagamine et al.: Correction angle for HTO
the tibial articular surface and lateral bowing of the
femoral shaft.
There was a high correlation between two correction
angles (R2 = 0.777, P < 0.001). Both the mean correction
angle by FTA and that by %MA were about 15°. The
discrepancy between two correction angles was less
than 3° in 80 cases. Therefore, the mechanical axis
passed through the lateral one-fourth of the tibial ar-
ticular surface when the postoperative FTA was set at
166° (14° valgus) in 80% of cases. However, the discrep-
ancy between two correction angles was 3° or larger in
20% of the cases. Three parameters had significant
correlation with the discrepancy: BFS (P < 0.001), BTS
(P < 0.01), and TA (P < 0.05). The correction angle by
14 cases. The femur had lateral bowing of the femoral
shaft in such cases. The correction angle by %MA was
smaller than that by FTA by 3° or larger in six cases.
The femur had medial bowing in such cases. Figure 1
shows two cases with lateral and medial bowing of the
femoral shaft. In the case with lateral bowing of the
femoral shaft (Fig. 1A), the correction angle by %MA
was 26° and that by FTA was 23°, whereas in the case
with medial bowing of the femoral shaft (Fig. 1B), the
correction angles were 12° and 16°, respectively. These
results clearly showed that the anatomic variations in
the frontal plane influence the correction angle by FTA,
and that FTA may not demonstrate the accurate align-
ment for the whole lower extremity in 20% of Japanese
subjects.
Discussion
The correction angle is one of the most important factors
that influence the outcome of HTO. The correction angle
has been calculated only by FTA in many studies, and the
degrees of anatomic variations of the femur and the tibia
in the frontal plane have not been taken into consider-
ation as one of factors that influenced the outcome. The
results of this study showed that the correction angle by
FTA may not be reliable in cases with bowing of the
femoral and/or tibial shaft. BFS was the most important
variation that influenced the correction angle. Even
though FTA is the same, the mechanical axis passes
through the more medial side of the knee in cases with
lateral bowing of the femoral shaft because the femoral
head shifts medially (Fig. 4). In such cases, the correction
angle by FTA should be set larger. On the other hand,
the postoperative FTA can be set more varus in knees
with medial bowing of the femoral shaft. The correction
angle by FTA was smaller than that by %MA in the case
with lateral bowing of the femoral shaft (Fig. 1A). The
correction angle by FTA was larger than that by %MA
in the case with medial bowing of the femoral shaft (Fig.
R. Nagamine et al.: Correction angle for HTO
A B C (races).15 When clinical results of HTO are evaluated,
Fig. 4. Bowing of the femoral shaft that influences the correc-
tion angle is shown. The case in A has a straight femoral shaft.
The case in C has lateral bowing of the femoral shaft. In B, A
and C are superimposed
1/4
Fig. 5. Orthoradiography (A) and schematic (B) of the lower
extremity of the case of Fig. 1B at 8 years after HTO. Even
though FTA is 170°, the mechanical axis passes though the
lateral one-fourth of the tibial articular surface
217
1B). Figure 5 shows the orthoradiography of the case
with medial bowing of the femoral shaft (Fig. 1B) at 8
years after HTO. Even though FTA was 170°, %MA was
75%, and the knee function score of the Japan Orthopae-
dic Association was 92.1,2
The results showed that the mechanical axis will pass
through the lateral one-fourth of the tibial articular sur-
face when FTA is set at 166° (14° valgus) in 80% of
cases in Japan. Fourteen degrees is larger than the op-
timal FTA that has been reported from Canada and the
United States.3,4 It has been reported that FA was the
same between Japanese subjects and subjects in West-
ern countries.15 These results showed that Japanese sub-
jects in this study might have varus deformity of the
femoral shaft and/or the tibial shaft in addition to the
proximal tibia vara. The anatomic characteristics of
the lower extremities are different among the countries
not only FTA but also the accurate alignment of the
whole lower extremity should be assessed, because pa-
tients may have some degrees of anatomic variation of
their femoral and/or tibial shafts in the frontal plane.
When the alignment of the whole lower extremity was
compared among different countries, there are several
problems. First, the definition of FTA is different among
the countries.17 Therefore, the value of FTA was ex-
pressed in two ways in this study. The hip-knee-ankle
angle is popular to express the alignment of the whole
lower extremity in the United States.16,18 Studies among
Japan and other countries are necessary to obtain opti-
mal correction angle for HTO. In those studies, the ac-
curate alignment of the whole lower extremities should
be evaluated using unified parameters.
In conclusion, the correction angle by FTA for HTO
should be calculated taking femoral and/or tibial shaft
bowing in the frontal plane into account.
Acknowledgments. The authors thank Miss Tomoko Yoshida
and Miss Chiemi Kadota for their technical assistance.
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