Knee Osteotomy (HTO, DFO, TTO)

An osteotomy is a joint-preserving operation. The surgeon cuts and realigns a bone around the knee to shift weight away from a damaged area, or to improve how the kneecap tracks. For the right patient, osteotomy can relieve pain and delay or avoid knee replacement, while keeping your own knee.

Types of knee osteotomy

• High tibial osteotomy (HTO): realigns the upper shinbone (tibia) to take pressure off the inner side of the knee, for bow-legged (varus) alignment with inner-knee arthritis or cartilage damage.
• Distal femoral osteotomy (DFO): realigns the lower thighbone (femur) to take pressure off the outer side of the knee, for knock-kneed (valgus) alignment with outer-knee damage.
• Tibial tubercle osteotomy (TTO): moves the bony attachment of the patellar tendon to improve how the kneecap tracks. It’s used for recurrent kneecap dislocation and for cartilage damage under the kneecap, and is often combined with MPFL reconstruction.

Who is a good candidate?

• Active adults who want to keep their natural knee
• Arthritis or cartilage damage mainly on one side of the knee, with leg alignment that overloads that side
• Kneecap instability or cartilage damage behind the kneecap (TTO)

Full-length alignment X-rays and an MRI help Dr. Dold decide whether osteotomy is right for you, or whether partial or total knee replacement is the better option.

Combined procedures

Osteotomy is often combined with cartilage repair or transplant, meniscus repair or meniscus transplant, or ligament reconstruction, so the repaired tissue is protected by better alignment.

Watch Dr. Dold: knee osteotomy videos

Recovery

The bone needs time to heal, so recovery includes a period of protected weight bearing with crutches and a structured physical therapy program. Dr. Dold will give you a specific timeline based on the procedure performed.

Watch Dr. Dold: planning a distal femoral osteotomy

Some of these videos show real surgery, so some viewers may prefer not to watch.

More videos on Dr. Dold’s YouTube channel.

What the research shows

• It works and it lasts: Cochrane reviews conclude that high tibial osteotomy (HTO) improves knee function and reduces pain in arthritis of the inner knee. In a review of more than 4,500 patients, about 92% still had their own knee at 5 years and 85% at 10 years, without needing a replacement.
• It unloads the worn side: gait studies show that HTO reduces the load on the inner knee during walking, which is how it relieves pain.
• Staying active: about 87% of patients return to sport after HTO, most within a year, and many at their previous level. This is a key reason osteotomy is favored for younger, active patients over partial or total knee replacement.
• Opening vs. closing wedge: both techniques have similar 10-year survival and complication rates. They differ in their effects on tibial slope, kneecap height and leg length, which guide the choice for each patient.
• Distal femoral osteotomy for knock-knee (valgus) alignment with outer-knee wear improves quality of life and allows most patients to return to work and recreational sport, though reoperation, often for hardware removal, is common.
• Combined procedures: correcting alignment at the same time as cartilage restoration, meniscus transplantation or ACL reconstruction improves results and may delay knee replacement. For kneecap cartilage defects, a tibial tubercle osteotomy improves the results of cartilage repair.
• Future replacement is still possible: knee replacement after a previous osteotomy has 10-year survival similar to a first-time replacement.

Why see Dr. Dold

• Author of The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies (JAAOS, 2017) and research on meniscal root repair and ACL reconstruction
• Board certified by the American Board of Orthopaedic Surgery, with subspecialty certification in Sports Medicine
• Fellow of the American College of Surgeons (FACS), the American Academy of Orthopaedic Surgeons (FAAOS), the American Orthopaedic Association (FAOA) and the Royal College of Surgeons of Canada (FRCSC)
• Sports medicine and arthroscopy fellowship at NYU Langone / Hospital for Joint Diseases; orthopedic residency at the University of Toronto
• Member of the American Orthopaedic Society for Sports Medicine (AOSSM) and the Arthroscopy Association of North America (AANA)
• D Magazine Best Doctors (Collin County), 2019–2026 · Rated 4.9 on Google

Frequently asked questions

Research cited on this page

1. Loke RWK, Chan YK, Lim YH, et al. Conversion to total knee arthroplasty after high tibial osteotomy: a systematic review and meta-analysis. Orthop J Sports Med. 2025;13(2):23259671241310963. PubMed
   In 59 studies (5,162 patients), conversion to knee replacement after high tibial osteotomy was 4.5% within 5 years, 8.3% at 5 to 10 years and 11.2% after 10 years.
2. Dal Fabbro G, Grassi A, Agostinone P, et al. High survivorship rate and good clinical outcomes after high tibial osteotomy in patients with radiological advanced medial knee osteoarthritis: a systematic review. Arch Orthop Trauma Surg. 2024;144(9):3977-3988. PubMed
   Even in knees with advanced arthritis on the inner side, average osteotomy survivorship was about 75% at 10 years, with good patient-reported results.
3. Yazdi H, Torkaman A, Sahrai R, et al. Distal femoral varus osteotomy in valgus knee with lateral compartment osteoarthritis: a systematic review. J Am Acad Orthop Surg Glob Res Rev. 2025;9(10). PubMed
   For arthritis on the outer side of the knee, distal femoral osteotomy had good function and survival rates of 74% to 90% at 10 years across 18 studies.
4. Brouwer RW, Jakma TS, Bierma-Zeinstra SM, et al. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. 2005(1):CD004019. PubMed
   Cochrane review: silver-level evidence that valgus high tibial osteotomy improves knee function and reduces pain.
5. Brouwer RW, Raaij van TM, Bierma-Zeinstra SM, et al. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. 2007(3):CD004019. PubMed
   Updated Cochrane review: valgus HTO improves function and reduces pain in medial knee arthritis.
6. Harris JD, McNeilan R, Siston RA, et al. Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction. Knee. 2013;20(3):154-61. PubMed
   Systematic review of 4,557 patients: isolated HTO survival was 92% at 5, 85% at 10, 77% at 15 and 72% at 20 years.
7. Kim JH, Kim HJ, Lee DH. Survival of opening versus closing wedge high tibial osteotomy: A meta-analysis. Sci Rep. 2017;7(1):7296. PubMed
   Meta-analysis: pooled 10-year survival was about 92% for opening-wedge HTO, with no significant difference from closing-wedge.
8. Smith TO, Sexton D, Mitchell P, et al. Opening- or closing-wedged high tibial osteotomy: a meta-analysis of clinical and radiological outcomes. Knee. 2011;18(6):361-8. PubMed
   Meta-analysis: no difference in infection, blood clots or nerve injury between opening- and closing-wedge HTO.
9. Sun H, Zhou L, Li F, et al. Comparison between Closing-Wedge and Opening-Wedge High Tibial Osteotomy in Patients with Medial Knee Osteoarthritis: A Systematic Review and Meta-analysis. J Knee Surg. 2017;30(2):158-165. PubMed
   Meta-analysis comparing closing-wedge and opening-wedge HTO outcomes and complications.
10. Wang Z, Zeng Y, She W, et al. Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of randomized controlled trials. Int J Surg. 2018;60:153-163. PubMed
    Meta-analysis: closing-wedge reduces and opening-wedge increases tibial slope; technique choice depends on the patient.
11. Bin SI, Kim HJ, Ahn HS, et al. Changes in Patellar Height After Opening Wedge and Closing Wedge High Tibial Osteotomy: A Meta-analysis. Arthroscopy. 2016;32(11):2393-2400. PubMed
    Meta-analysis: kneecap height decreases after opening-wedge HTO but not after closing-wedge.
12. Kim JH, Kim HJ, Lee DH. Leg length change after opening wedge and closing wedge high tibial osteotomy: A meta-analysis. PLoS One. 2017;12(7):e0181328. PubMed
    Meta-analysis: leg length change was about 8 mm greater with opening-wedge than closing-wedge HTO.
13. Ekhtiari S, Haldane CE, de Sa D, et al. Return to Work and Sport Following High Tibial Osteotomy: A Systematic Review. J Bone Joint Surg Am. 2016;98(18):1568-77. PubMed
    Systematic review: 87% returned to sport after HTO and 79% at an equal or higher level, mostly within a year.
14. Kunze KN, Beletsky A, Hannon CP, et al. Return to Work and Sport After Proximal Tibial Osteotomy and the Effects of Opening Versus Closing Wedge Techniques on Adverse Outcomes: A Systematic Review and Meta-analysis. Am J Sports Med. 2020;48(9):2295-2304. PubMed
    Meta-analysis of knee osteotomy: return to sport 76% and work 81%; 12.5% converted to knee replacement at about 6 years.
15. Lee SH, Lee OS, Teo SH, et al. Change in gait after high tibial osteotomy: A systematic review and meta-analysis. Gait Posture. 2017;57:57-68. PubMed
    Meta-analysis: knee adduction moment and lateral thrust decreased after HTO, unloading the inner knee.
16. Zhang B, Qian H, Wu H, et al. Unicompartmental knee arthroplasty versus high tibial osteotomy for medial knee osteoarthritis: A systematic review and meta-analysis. J Orthop Surg (Hong Kong). 2023;31(1):10225536231162829. PubMed
    Meta-analysis: unicompartmental replacement had less pain and fewer revisions than HTO in older patients, with similar excellent-result rates.
17. Santoso MB, Wu L. Unicompartmental knee arthroplasty, is it superior to high tibial osteotomy in treating unicompartmental osteoarthritis? A meta-analysis and systemic review. J Orthop Surg Res. 2017;12(1):50. PubMed
    Meta-analysis: HTO allows more physical activity for younger patients, while partial knee replacement suits older patients with faster recovery.
18. Belsey J, Yasen SK, Jobson S, et al. Return to Physical Activity After High Tibial Osteotomy or Unicompartmental Knee Arthroplasty: A Systematic Review and Pooling Data Analysis. Am J Sports Med. 2021;49(5):1372-1380. PubMed
    Systematic review: HTO patients were more active before and after surgery; partial replacement gave larger gains in activity.
19. Sun X, Wang J, Su Z. A meta-analysis of total knee arthroplasty following high tibial osteotomy versus primary total knee arthroplasty. Arch Orthop Trauma Surg. 2020;140(4):527-535. PubMed
    Meta-analysis: knee replacement after a previous HTO had 10-year survival similar to primary knee replacement, with longer surgery.
20. Wylie JD, Jones DL, Hartley MK, et al. Distal Femoral Osteotomy for the Valgus Knee: Medial Closing Wedge Versus Lateral Opening Wedge: A Systematic Review. Arthroscopy. 2016;32(10):2141-2147. PubMed
    Systematic review: distal femoral osteotomy for valgus knees improved quality of life but had a 34% reoperation rate.
21. Diaz CC, Lavoie-Gagne OZ, Knapik DM, et al. Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques. Am J Sports Med. 2023;51(3):798-811. PubMed
    Meta-analysis: opening- and closing-wedge DFO both gave good to excellent outcomes; hardware pain was the most common complication.
22. Bassi JS, Chan JP, Johnston T, et al. Return to Work and Sport After Distal Femoral Osteotomy: A Systematic Review. Sports Health. 2022;14(5):681-686. PubMed
    Systematic review: high return to work and sport after DFO.
23. Ciolli G, Proietti L, Mercurio M, et al. Return to sport following distal femur osteotomy: a systematic review. Orthop Rev (Pavia). 2022;14(2):33774. PubMed
    Systematic review: return to sport after DFO is common, at about one year.
24. Kahlenberg CA, Nwachukwu BU, Hamid KS, et al. Analysis of Outcomes for High Tibial Osteotomies Performed With Cartilage Restoration Techniques. Arthroscopy. 2017;33(2):486-492. PubMed
    Systematic review: HTO combined with cartilage restoration gives reliable medium- to long-term improvement and may delay knee replacement.
25. Stride D, Wang J, Horner NS, et al. Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(4):1320-1331. PubMed
    Systematic review: combined HTO and ACL reconstruction improved function in ACL-deficient varus knees.
26. Trinh TQ, Harris JD, Siston RA, et al. Improved outcomes with combined autologous chondrocyte implantation and patellofemoral osteotomy versus isolated autologous chondrocyte implantation. Arthroscopy. 2013;29(3):566-74. PubMed
    Systematic review: chondrocyte implantation for kneecap cartilage defects improved more when combined with tibial tubercle osteotomy.
27. Elattar M, Dhollander A, Verdonk R, et al. Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):147-57. PubMed
    Systematic review: meniscal allograft transplantation gave continuously satisfactory outcomes over long follow-up.

Medically reviewed by Andrew P. Dold, MD, FAOA, FAAOS, FACS, FRCSC. Last reviewed October 2026. This page is general information, not medical advice.