Prior Tibial Osteotomy Increases Revision Risk After Conversion Knee Arthroplasty

The Evolution of Surgical Management for Medial Compartment Osteoarthritis

Total knee arthroplasty remains the definitive surgical intervention for end-stage knee osteoarthritis, yet joint-preserving strategies are frequently employed to delay prosthetic replacement in younger or more active populations [1, 2]. Procedures such as high tibial osteotomy (a surgical realignment of the tibia to shift weight-bearing loads) and unicompartmental knee arthroplasty (the replacement of only one diseased compartment of the knee) offer effective symptomatic relief but often serve as a bridge to eventual total joint replacement [3, 4]. While both approaches are viable for medial compartment disease, they introduce unique mechanical and anatomical alterations that may complicate future surgical interventions [5, 6]. Previous knee surgery has already been associated with increased risks of infection, stiffness, and aseptic revision following subsequent arthroplasty [7]. A new study now offers fresh insights into how the specific choice of initial joint-preserving surgery dictates the clinical trajectory and complication profile after conversion to a total knee prosthesis.

Divergent Patient Profiles in Joint Preservation

The researchers utilized a large national database to analyze outcomes for 6,278 patients who underwent conversion total knee arthroplasty between 2010 and 2022. This study specifically compared demographic characteristics and implant-related complications between two distinct cohorts: 5,884 patients who had previously undergone unicompartmental knee arthroplasty (the replacement of a single knee compartment) and 394 patients who had a prior high tibial osteotomy (a surgical realignment of the tibia). By examining these two groups, the authors sought to determine how the initial joint-preserving strategy influences the clinical profile and postoperative risks of a subsequent total knee replacement. The analysis revealed that patients undergoing conversion after a high tibial osteotomy represent a younger and more comorbid population with distinct psychosocial risk factors compared to those transitioning from a partial replacement. Specifically, 45.8% of the osteotomy group was 54 years of age or younger, whereas only 7.1% of the unicompartmental replacement group fell into this younger age bracket. Beyond age, the two groups exhibited divergent health profiles. Patients in the osteotomy cohort demonstrated significantly higher rates of alcohol use disorder, drug abuse, and depression. In contrast, the unicompartmental replacement group showed higher rates of metabolic and cardiovascular comorbidities, specifically hypertension and obesity. These findings suggest that the choice of initial surgery is often linked to the patient's baseline health status, which in turn shapes the risk environment for the eventual conversion to a total knee prosthesis.

Increased Risk of Postoperative Stiffness and Revision

At the two-year follow-up mark, the study identified a significantly higher incidence of postoperative stiffness requiring intervention in the high tibial osteotomy cohort. Specifically, 6.85% of patients who had a prior high tibial osteotomy required manipulation under anesthesia (a procedure where the surgeon moves the joint while the patient is sedated to break up adhesions), compared to 3.64% of those transitioning from a unicompartmental knee arthroplasty. This increased risk of stiffness was accompanied by a higher rate of surgical failure; all-cause revision occurred in 5.84% of the osteotomy group versus 3.79% of the unicompartmental replacement group. To ensure these differences were not merely a reflection of the younger age or the specific health profiles of the osteotomy patients, the researchers utilized logistic regression models adjusted for age, sex, and comorbidities (a statistical method that isolates the effect of the surgery by controlling for other patient variables). Even after these adjustments, the statistical analysis confirmed that a prior high tibial osteotomy was an independent risk factor for complications. The odds ratio for manipulation under anesthesia was 1.95 (95% CI 1.29 to 2.95; P = 0.002), indicating a nearly twofold increase in risk. Similarly, the odds ratio for all-cause revision was 1.57 (95% CI 1.01 to 2.45; P = 0.043), representing a 57% higher likelihood of requiring a secondary total knee replacement. For these calculations, the researchers considered P < 0.05 to be the threshold for statistical significance. Despite the increased risk of stiffness and revision, other major implant-related complications showed no significant variation between the two surgical pathways. The researchers found that rates of periprosthetic joint infection were similar between groups (P > 0.05). Furthermore, the incidence of aseptic loosening (the failure of the bond between the bone and the implant without infection) and periprosthetic fracture (a break in the bone around the knee components) did not differ significantly (both P > 0.05). These findings suggest that while the mechanical or biological environment following a high tibial osteotomy may predispose patients to arthrofibrosis and revision, it does not necessarily increase the risk of acute infection or structural bone failure compared to conversion from a partial knee replacement. For the practicing clinician, these data emphasize the need for intensive perioperative counseling and personalized rehabilitation planning for the younger, high-risk osteotomy patient transitioning to a total joint.

References

1. Bin G, Jinmin L, Cong T, Yuchen T, Xiaohui Z, Yayi X. Surgical interventions for symptomatic knee osteoarthritis: a network meta-analysis of randomized control trials.. BMC musculoskeletal disorders. 2023. doi:10.1186/s12891-023-06403-z

2. Fabbro GD, 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.. Archives of orthopaedic and trauma surgery. 2024. doi:10.1007/s00402-024-05254-0

3. Li P, Qiao Y, Zhou Y, et al. Comparative outcomes of revision total knee arthroplasty: a systematic review and meta-Analysis of high tibial osteotomy vs. unicompartmental knee arthroplasty.. BMC musculoskeletal disorders. 2025. doi:10.1186/s12891-025-08891-7

4. Huang L, Xu Y, Wei L, et al. Unicompartmental knee arthroplasty is superior to high tibial osteotomy for the treatment of medial unicompartmental osteoarthritis: A systematic review and meta-analysis.. Medicine. 2022. doi:10.1097/MD.0000000000029576

5. Loke RWK, Tan BWL, Tan EYEK, Hui JHP. Total knee arthroplasty after prior high tibial osteotomy results in comparable survival and clinical outcomes but significantly higher complication rates compared to primary total knee arthroplasty: a systematic review and meta-analysis of 550,000 patients.. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2025. doi:10.1007/s00590-025-04237-0

6. He M, Zhong X, Li Z, Shen K, Zeng W. Progress in the treatment of knee osteoarthritis with high tibial osteotomy: a systematic review.. Systematic reviews. 2021. doi:10.1186/s13643-021-01601-z

7. Li Y, Ajia A, Wu Z, et al. Previous knee surgery increases risks of revision, infection, pain and stiffness after knee replacement arthroplasty: a systematic review and meta-analysis.. BMC musculoskeletal disorders. 2025. doi:10.1186/s12891-025-09060-6