Skip to main content
Download PDF

Influence of preoperative medial meniscus extrusion and subchondral bone marrow edema on outcomes after medial opening wedge high tibial osteotomy

Journal of Orthopaedic Surgery and Research volume 20, Article number: 353 (2025) Cite this article

Abstract

Objective

No studies have assessed the correlation between preoperative medial meniscus extrusion (MME) and subchondral bone marrow edema (BME) or which factor influences the outcomes after medial opening wedge high tibial osteotomy (MOWHTO). The present study aimed to determine the influence of preoperative MME and BME on outcomes after MOWHTO.

Methods

This study included 151 patients between January 2019 and January 2022 with a mean follow-up of 3.2 years. MME was classified into 2 groups according to the presence of pathologic MME (≥ 3 mm). BME was graded into 4 groups according to the lesion volume based on the MRI Osteoarthritis Knee Score (MOAKS) criteria. Clinical outcomes were assessed with the Hospital for Special Surgery (HSS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee Society Score (KSS).

Results

The mean ± standard deviation preoperative MME for all patients was 3.6 ± 1.9 mm. A total of 103 patients (68.2%) had pathologic MME. MME significantly increased with increasing BME grade. Those with pathologic MME showed significantly worse outcomes in terms of the WOMAC and KSS for pain and function and HSS score than those without pathologic MME at 1 and 2 years postoperatively (all p < 0.05). A total of 122 patients (80.8%) had BME. Among the 151 patients, 29 (19.2%), 61 (40.4%), 42 (27.8%), and 19 (12.6%) were classified as having an MOAKS of 0, 1, 2, and 3, respectively, with significant differences in the preoperative WOMAC and KSS for pain and function and HSS score among these 4 groups (all P < 0.001). However, there were no significant differences in these indices at 1 or 2 years postoperatively (all P > 0.05). Only MME correlated with worse clinical outcomes in univariate (p < 0.001) and multivariate (p < 0.001) analyses.

Conclusions

Short-term clinical outcomes were worse for patients with preoperative MME greater than 3 mm than for those with preoperative MME less than 3 mm. There were no correlations between preoperative subchondral BME severity and postoperative outcomes.

Introduction

Medial meniscal extrusion (MME) is an important but yet unclear stage in osteoarthritis(OA) development [1, 2]. MME occurs when the peripheral edge of the meniscus is displaced ≥ 3 mm beyond the edge of the tibial plateau [3, 4]. Bone marrow edema (BME) is acknowledged to be nonspecific, with characteristics of an ill-defined marrow area with low signal intensity on T1-weighted imaging (T1WI) and areas of high intensity on short tau inversion recovery (STIR) imaging and fat-suppressed T2WI. Previous studies have shown that the risk of progressive knee osteoarthritis (OA) is increased by both MME and BME in terms of cartilage volume loss and the need for knee replacement [5,6,7]. Patients with medial compartment OA benefit from medial opening wedge high tibial osteotomy (MOWHTO), which has become widely applied due to progress in the development of firm fixation devices and operative techniques [8, 9]. Follow-up studies of MOWHTO have reported survival rates of 74–92% at 10 years postoperatively [10,11,12,13]. Kroner et al. [14] reported that a reduction in BME is associated with clinical improvement and that the association could be affected by HTO. Kim et al. [15] also observed that greater preoperative BME severity might indicate worse clinical outcomes 1 year after HTO, and patients with greater preoperative MME have reported poorer outcomes at 1 and 2 years after surgery, especially regarding pain [16]. A recent study indicated that MOWHTO reduces the severity of MME and that patients with a postoperative MME < 3 mm have better clinical outcomes than those with MME ≥ 3 mm [17]. However, previous investigations have not investigated the correlation between preoperative MME and BME or which factor affects the outcomes after MOWHTO the most.

Therefore, we evaluated the relationship between preoperative MME and subchondral BME based on musculoskeletal MRI and analysed the outcomes a minimum of 2 years after MOWHTO for the treatment of medial compartment knee OA. We hypothesized that more severe MME and BME would be associated with worse outcomes.

Materials and methods

Patients

The present study was approved by our institutional review board and ethics committee. A total of 239 consecutive MOWHTO procedures were performed by 2 senior orthopaedic surgeons at our institution between January 2019 and January 2022 and 88 knees were excluded from this study (Fig. 1). The patients who were included in the study had been evaluated with MRI scans within 3 months prior to surgery and followed up for a minimum of 2 years after surgery. The inclusion criteria for patients who underwent OWHTO were as follows: (I) isolated medial compartmental OA or osteonecrosis of the medial femoral condyle, including cases of varus malalignment of the leg and persistent pain despite more than 3 months of conservative treatment; (II) no inflammatory arthritis (rheumatoid arthritis); (III) flexion contracture ≤ 15°, knee range of motion ≥ 120°; (IV) no joint instability; and (V) no history of knee joint infection. The exclusion criteria were as follows: (1) knee range of motion < 100° and flexion contracture > 20°; (2) patellofemoral or lateral compartment OA (Kellgren-Lawrence grade ≥ 2); (3) inflammatory or posttraumatic knee arthritis; (4) insufficient anterior or posterior cruciate ligament; (5) history of knee joint infection; and (6) incomplete preoperative MRI data or follow-up duration < 2 years. Ultimately, 151 patients with a mean follow-up duration of 3.2 ± 0.8 years were included.

Fig. 1
figure 1

Patient selection diagram. HTO, high tibial osteotomy

Full size image

Surgical procedure and postoperative rehabilitation

All surgical procedures were performed by the same surgeon (ML) with the patients in a supine position under general anesthesia. All patients underwent a careful, routine arthroscopic inspection and evaluation of the meniscus, ligaments, and articular cartilage and appropriate management if necessary.

An individualized preoperative plan was developed according to the condition of the affected knee to determine the target alignment, wedge width and simulation angle. Commonly used target alignment locations include the tip of the lateral intercondylar spine and the midpoint of the line connecting the medial and lateral intercondylar spines. During the operation, a medial longitudinal incision at the proximal end of the calf was used to expose the medial and posterior aspects of the proximal tibia, and the superficial fibers of the medial collateral ligament were exposed andreleased. The upper edge of the pes anserinus was the most commonly used marker for the osteotomy. An oblique osteotomy was initiated at a point 35 mm distal to the medial tibial plateau and ending 5 mm from the lateral cortical margin just at the upper level of the proximal tibiofibular joint. A frontal osteotomy was then commenced at a point 10–20 mm proximal to the insertion of the patellar tendon and ending at the first osteotomy plane (biplanar osteotomy). The osteotomy was completed using an oscillating saw and a thin bone knife, maintaining the integrity of the proximal lateral hinge of the tibia. A proximal tibia T-shaped locking plate (Shandong Weigao Medical Instrument Co., Ltd., Weihai, China) was implanted into the subcutaneous tunnel formed by the posteromedial tibia and fixed with 8 locking screws. If the wedge width was more than 10 mm, artificial bone substitute (OSTEOSET, Wright Medical Technology, Inc., USA) was implanted.

All patients underwent identical rehabilitation. On the first postoperative day, the patient was allowed to walk with partial weight bearing with the aid of crutches while beginning flexion and extension exercises and straight leg raises. Patients were allowed partial weightbearing ambulation at postoperative 4 weeks and full weightbearing ambulation at 6 weeks.

Preoperative MRI assessment of MME and BME

All patients underwent preoperative 1.5-T MRI with a superconducting magnet for the assessment of MME and BME. BME was assessed and graded according to the lesion volume based on the MRI Osteoarthritis Knee Score (MOAKS) criteria for the location and severity of preoperative subchondral BME [18], as follows: grade 0, no BME; grade 1, BME filling < 1/3 of the medial condyle of the femur or tibia; grade 2, BME filling between 1/3 and 2/3; and grade 3, BME filling > 2/3 (Fig. 2).

Fig. 2
figure 2

BME was assessed based on the MRI Osteoarthritis Knee Score (MOAKS). Medial femoral condyle and medial tibial plateau: (A, E) grade 0, (B, F) grade 1, (C, G) grade 2, and (D, H) grade 3. MRI, magnetic resonance imaging

Full size image

The extent of MME was determined using the method reported by Costa et al. [19]. The coronal MRI slice in which the medial eminence of the tibia was largest was used as the reference section for meniscal extrusion. MME was measured by drawing two parallel lines. The first vertical line was created at the point where the medial tibial plateau changed from horizontal to vertical. The second line was made parallel to the first line, tangential to the medial side of the medial meniscus. The extent of meniscal extrusion was calculated as the distance between the two vertical linesexcluding the osteophytes (Fig. 3).

Fig. 3
figure 3

Measurement of medial meniscal extrusion.On the fat-suppressed T2-weighted coronal image, the first vertical line was drawn intersecting the peripheral margin of the medial tibial plateau at the point of transition from horizontal to vertical. The second vertical line was drawn along the outer margin of the medial meniscus. The length between the first and second lines was defined as the measurement of meniscal extrusion. Osteophytes were excluded for determining the medial margin

Full size image

Radiographic evaluation

Radiographs, including standardized anteroposterior, lateral, and Merchant views of the knee and standing anteroposterior hip-ankle radiographs, were obtained preoperatively and postoperatively. Degree of varus deformity (hip-knee-ankle (HKA) angle, determined as the angle between the line connecting the hip and knee centre and the line connecting the knee and ankle centre), medial proximal tibial angle (MPTA) and weight-loading line) (Fig. 4). Locations and patterns of medial meniscal tears were classified during arthroscopic surgery as previously described [20]. Radiographic and arthroscopic findings were evaluated by 2 independent investigators who were blinded to the aim of the study.

Fig. 4
figure 4

The radiographic measurements taken from an anteroposterior long-standing view of the lower extremity.(A) The weightbearing line (WBL) ratio was defined as the ratio between the distance from the medial tibial edge to the tibial insertion of WBL (a) and the tibial width (b). The weight-loading line was measured from the medial side, with the medial tibial edge at 0% and the lateral tibial edge at 100%. (B) The hip-knee-ankle (HKA) was the lateral angle formed between the anatomic femoral axis and the anatomic tibial axis. (C) The medial proximal tibial angle (MPTA) was the medial angle formed between the mechanical tibial axis and the joint line of the proximal tibia

Full size image

Clinical evaluation

Clinical information included demographic data and surgical factors with a minimum follow-up of 2 years. Demographic data included age, sex, body mass index (BMI), degree of varus deformity (hip-knee-ankle (HKA) angle, determined as the angle between the line connecting the hip and knee centre and the line connecting the knee and ankle centre), medial proximal tibial angle (MPTA) and weight-loading line). Postoperative radiographic factors included the postoperative HKA angle, MPTA and weight-bearing line. Clinical indices evaluated preoperatively and at 1 and 2 years after surgery included the Hospital for Special Surgery (HSS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee Society Score (KSS). The WOMAC questionnaire is standardized and validated for assessing the condition of patients who have undergone knee surgery on 3 subscales: pain, stiffness, and function [21]. Clinical assessments were performed by 2 independent investigators who had not been directly involved in the surgical procedures. The assessors were blinded to the functional outcome scores.

Statistical analysis

Continuous variables are presented as the means and standard deviations, and categorical variables are presented as counts and percentages. Analysis of variance was used for continuous variables when the data set followed a normal distribution. When the data set did not follow a normal distribution, the Kruskal‒Wallis test was used. The chi-square test or Fisher’s exact test was used to compare categorical variables between groups according to descriptive data and pre- and postoperative values. A post hoc analysis with Bonferroni’s correction was used to make pairwise comparisons and to confirm significant differences among groups. All statistical analyses were performed with SPSS (v 21.0; IBM). A P value < 0.05 was considered to indicate statistical significance.

Results

We collected data from 151 patients and used them for further analysis (Table 1). The mean age of the 151 patients was 55.9 ± 8.0 years, and the mean BMI was 25.74 kg/m2. There were 81 females and 70 males. There were 74 right knees and 77 left knees, with an average HKA angle of 171.8°, an MPTA of 80.1° and a weight-bearing line of 17.6%. The meniscal tear patterns consisted of longitudinal tears in 4 patients, horizontal tears in 27, vertical flap tears in 10, radial tears in 13, complex tears in 43, root tears in 45 and no tears in 9. The mean ± standard deviation preoperative MME for all patients was 3.6 ± 1.9 mm. A total of 103 patients (68.2%) had pathologic MME was defined as medial meniscal body extrusion of 3 mm or more (Table 2).

Table 1 Demographic characteristics
Full size table
Table 2 Demographic characteristics according to MME
Full size table

There was a significant difference in the preoperative HKA angle (p = 0.003), MPTA (p = 0.006), and BME grade (p = 0.032) between patients with complex or root tears and those with horizontal or other tears, and MME was more likely in the former (Fig. 5).

Fig. 5
figure 5

MME significantly differed among the 4 tear types. (*P < 0.05, ***P < 0.001, ****P < 0.0001)

Full size image

No correlation was observed between postoperative radiographic outcomes and clinical outcomes at 1 year or 2 years postoperatively. Clinical outcomes based on the presence of pathologic MME are shown in Table 3. Patients with pathologic MME showed significantly worse outcomes in terms of the WOMAC and KSS for pain and function and the HSS score than those without pathologic MME at 1 and 2 years postoperatively (all p < 0.05).

Table 3 Comparison of clinical outcomes between groups according to MME
Full size table

A total of 122 patients (80.8%) had BME (Table 4). Among the 151 patients, 29 (19.2%), 61 (40.4%), 42 (27.8%), and 19 (12.6%) were classified as having BME with an MOAKS of 0, 1, 2, and 3, respectively (Table 4). Although there were no significant differences in age, sex, BMI, preoperative or postoperative HKA angle, MPTA or weight-bearing line among the stages, MME significantly increased with increasing BME stage (Fig. 6).

Table 4 Demographic characteristics according to BME grade
Full size table
Fig. 6
figure 6

MME significantly differed among the 4 BME grades. (*P < 0.05, **P < 0.01, ****P < 0.0001)

Full size image

Among the groups classified by meniscal tear type, the BME grade was significantly higher in patients with medial meniscus posterior root tears (MMPRTs) than in patients with other tear types. These 4 groups showed significant differences in the preoperative WOMAC and KSS for pain and function and HSS score (all P < 0.001). However, there were no significant differences in these scores at 1 or 2 years postoperatively (all P > 0.05) (Table 5). Among several preoperative and postoperative characteristics, only MME correlated with worse clinical outcomes according to univariate (p < 0.001) and multivariate (p < 0.001) analyses (Table 6).

Table 5 Comparison of clinical outcomes between groups according to BME grade
Full size table
Table 6 Univariate and multivariate analysis of association between preoperative variables and the clinical outcome
Full size table

Discussion

The most important finding of this study was that patients with preoperative MME had worse clinical outcomes 1 and 2 years after MOWHTO, but there was no correlation between preoperative subchondral BME severity and postoperative outcomes. The preoperative meniscal tears patterns, including complex and root tears, as well as the preoperative BME grade, HKA angle (p = 0.003), and MPTA, were related to the extent of MME. Concerning the incidence of subchondral BME, approximately 80% of patients had BME in either the femur or the tibia at the time of surgery in this study. These findings suggest that orthopaedic surgeons should evaluate MME and BME on MRI scans before MOWHTO so that they can provide appropriate education about expected outcomes to patients.

The main functions of the meniscus are absorbing shock, transferring loads and improving femorotibial joint confluence. When the weight is loaded, the hoop stress of the meniscus counteracts meniscal extrusion [22]. Hoop strain is based on the circumferential collagen fibres and the attachment of the anterior and posterior roots to the tibial plateau [23]. Lerer et al. [24] reported that meniscal extrusion is strongly associated with medial meniscus root pathology and radial tears. Allaire et al. [25] reported that MMPRTs disrupt hoop strain, resulting in contact pressure of the knee joint similar to that after total meniscectomy. MME is a predictor of OA progression and is associated with pain in patients with knee OA [16, 26,27,28]. Goto et al. [29] reported that MME was related to joint space narrowing, cartilage loss, and OA development. Compared to healthy knees, peak stress in medial compartment tissues increased by over 40% with 4 mm of medial meniscus extrusion, and in lateral compartment tissues with 2 mm of lateral meniscus extrusion [30]. Clinically, varus alignment, large MME, and older age were found to predict a poor prognosis after arthroscopic partial meniscectomy(APM). The preoperative extent of MME can be used as a predictive factor for osteoarthritis in APM. Patients with varus and MME should avoid APM [31]. High tibial osteotomy may be an effective treatment. Jing L et al. [32] reported that a higher healing rate of MMPRT using all-inside repair and regeneration of degenerated articular cartilage in the medial condyles after MOWHTO can be expected. Moreover, BMI, WBL and HTA may affect the healing status of MMPRT. Itou J et al. [33] reported that favorable clinical results were obtained by medial open-wedge HTO in knees with MMPRT and moderate varus alignment in the short term.

Recently, Astur et al. [34] performed a short-term retrospective study on 66 patients with knee OA and pathologic MME. They found that MOWHTO improved clinical outcomes, accelerated return to activity, and reduced MME after a minimum follow-up of 2 years. Kim et al. [16] and Yang et al. [35] reported that clinical outcomes were worse after MOWHTO in patients with greater preoperative MME. The deterioration of clinical outcomes that was previously observed at 2 years postoperatively continued even after a mean of 8.1 years, and patients with absolute MME > 5 mm or relative MME > 50% tended to have poor Knee injury and Osteoarthritis Outcome Score (KOOS) values for pain after MOWHTO [34]. These studies indicate that the degree of preoperative MME is related to clinical outcomes, which is consistent with our results. We did not perform standardized follow-up MRI to assess postoperative changes in MME. However, MOWHTO might reduce the extent of MME while improving clinical outcomes by reducing medial compartment stress due to unloading effects (Fig. 7).

Fig. 7
figure 7

(A) 47-year-old woman with varus limb alignment. (B) Postoperative radiograph showing correction of varus limb alignment after medial opening wedge high tibial osteotomy. (C) Preoperative coronal T2WI showing 7.1 mm of medial meniscal extrusion. (D) Follow-up T2WI showing a decrease in the extent of meniscal extrusion to 1.8 mm

Full size image

Some studies have demonstrated an association between the location of meniscal tears and the degree of meniscal extrusion [29, 36]. Kim et al. [37] also showed that degenerative horizontal tears, complex tears and root tears were more commonly associated with meniscal extrusion than were other types of tears. Costa et al. [19] reported that large radial complex tears and root tears have been shown to be associated with maximal meniscal extrusion. The present study showed that the meniscal tear pattern, including root tears and complex tears, is related to MME, which agrees with previous reports [16, 19, 29, 37].

Moreover, we found a relationship between lower leg alignment parameters and meniscal extrusion. Several studies have reported that the extent of MME is increased with greater varus alignment [2, 38]. This study also examined the relationship between MME and the extent of varus deformity, and the results showed that greater preoperative varus alignment was correlated with greater MME. Van Thiel et al. [39] reported that the peak and total medial compartment pressures were significantly decreased after HTO [40]. Although the medial compartment pressure tended to decrease after HTO, the pressure was greater in meniscus-deficient knees than in knees with intact menisci. As a result, with severe MME, there is less pressure reduction in the medial compartment after HTO.

Numerous studies have examined the association between knee joint pain and BME in patients with OA [41, 42]. Brem et al. [43] reported that subchondral BME is frequently detectable in patients with symptomatic OA of the knee. Felson et al. [44] demonstrated that BME lesions are found in 50% of people with clinical symptoms; however, they are also found in 4% of those without symptoms. The incidence of BME in patients with symptomatic radiographic OA was reported as 73% by Sowers et al. [45], 77.5% by Felson et al. [44], and 71% by Ip et al. [46]. Similarly, in this study, approximately 80% of patients had BME in either the femur or the tibia. The presence of BME is a significant predictor of knee pain [47], and the risk of medial progression increases more than sixfold in patients with medial compartment lesions [48]. Felson et al. [44] reported that the presence of BME is significantly associated with knee pain in patients with radiographic OA, and the initiation and progression of BME might be due to an imbalance between repair and remodelling [49, 50]. Kroner et al. [14] reported that the mean size of the BME lesion in the medial femoral condyle and medial tibial plateau decreased by 3 cm [3] and 1.26 cm [3], respectively, at 1 year after HTO. Pain is improved when the BME lesion size is reduced [44]. MOWHTO was performed in patients who had medial compartment OA with varus malalignment to reduce loading on the medial compartment and to transfer weight-bearing from the affected medial compartment to the lateral compartment. Although we did not confirm the size of the BME lesion through follow-up MRI, the size of the BME lesion might decrease due to the reduction in medial compartment loading.

Our study has certain limitations. First, this was a retrospective cohort study based on the database of 1 institute. Thus, it was difficult to control for confounding factors, and selection bias was possible. Second, BME can occur not only in the femur but also in the tibia, but we have not independently measured the effect of femoral versus tibial versus combined BME. Third, the follow-up period was relatively short (2 years), and our results are not reflective of long-term follow-up. Further studies with longer follow-up periods are needed to clarify the effect of the preoperative severity of MME and BME. Fourth, data on how MME and BME changed over time after HTO were not collected or compared with outcomes at 1 or 2 years postoperatively.

Conclusion

In conclusion, clinical outcomes were better for patients with preoperative MME of less than 3 mm than for those with preoperative MME of more than 3 mm. Our results suggest that increasing BME severity is correlated with worse preoperative pain and function. However, we did not find any correlation between preoperative subchondral BME severity and postoperative outcomes. Our study has great significance in that it provides information for physicians and patients about the recovery pattern of clinical features after MOWHTO with realistic expectations. The present study provides evidence that thorough evaluation of MME before MOWHTO should be considered by orthopaedic surgeons so that they can provide crucial information about expected outcomes. MOWHTO with adequate correction is a reliable treatment for patients with BME, and preoperative BME should not be considered a contraindication to MOWHTO.

Data availability

No datasets were generated or analysed during the current study.

References

  1. Teichtahl AJ, Cicuttini FM, Abram F, Wang Y, Pelletier JP, Dodin P, Martel-Pelletier J. Meniscal extrusion and bone marrow lesions are associated with incident and progressive knee osteoarthritis. Osteoarthritis Cartilage. 2017;25(7):1076–83.

    Article  CAS  PubMed  Google Scholar 

  2. Crema MD, Roemer FW, Felson DT, Englund M, Wang K, Jarraya M, Nevitt MC, Marra MD, Torner JC, Lewis CE, Guermazi A. Factors associated with meniscal extrusion in knees with or at risk for osteoarthritis: the multicenter osteoarthritis study. Radiology. 2012;264(2):494–503.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Bloecker K, Wirth W, Guermazi A, Hunter DJ, Resch H, Hochreiter J, Eckstein F. Relationship between medial meniscal extrusion and cartilage loss in specific femorotibial subregions: data from the osteoarthritis initiative. Arthritis Care Res (Hoboken). 2015;67(11):1545–52.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Muzaffar N, Kirmani O, Ahsan M, Ahmad S. Meniscal extrusion in the knee: should only 3 mm extrusion be considered significant? An assessment by MRI and arthroscopy. Malays Orthop J. 2015;9(2):17–20.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Hofmann S, Kramer J, Vakil-Adli A, Aigner N, Breitenseher M. Painful bone marrow edema of the knee: differential diagnosis and therapeutic concepts. Orthop Clin North Am. 2004;35(3):321–33. ix.

    Article  PubMed  Google Scholar 

  6. Raynauld JP, Martel-Pelletier J, Haraoui B, Choquette D, Dorais M, Wildi LM, Abram F, Pelletier JP. Risk factors predictive of joint replacement in a 2-year multicentre clinical trial in knee osteoarthritis using MRI: results from over 6 years of observation. Ann Rheum Dis. 2011;70(8):1382–8.

    Article  PubMed  Google Scholar 

  7. Tanamas SK, Wluka AE, Pelletier JP, Pelletier JM, Abram F, Berry PA, Wang Y, Jones G, Cicuttini FM. Bone marrow lesions in people with knee osteoarthritis predict progression of disease and joint replacement: a longitudinal study. Rheumatology (Oxford). 2010;49(12):2413–9.

    Article  PubMed  Google Scholar 

  8. Niemeyer P, Koestler W, Kaehny C, Kreuz PC, Brooks CJ, Strohm PC, Helwig P, Suedkamp NP. Two-year results of open-wedge high tibial osteotomy with fixation by medial plate fixator for medial compartment arthritis with varus malalignment of the knee. Arthroscopy. 2008;24(7):796–804.

    Article  PubMed  Google Scholar 

  9. Song EK, Seon JK, Park SJ, Jeong MS. The complications of high tibial osteotomy: closing- versus opening-wedge methods. J Bone Joint Surg Br. 2010;92(9):1245–52.

    Article  CAS  PubMed  Google Scholar 

  10. Niinimäki TT, Eskelinen A, Mann BS, Junnila M, Ohtonen P, Leppilahti J. Survivorship of high tibial osteotomy in the treatment of osteoarthritis of the knee: Finnish registry-based study of 3195 knees. J Bone Joint Surg Br. 2012;94(11):1517–21.

    Article  PubMed  Google Scholar 

  11. Duivenvoorden T, Brouwer RW, Baan A, Bos PK, Reijman M, Bierma-Zeinstra SM, Verhaar JA. Comparison of closing-wedge and opening-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee: a randomized controlled trial with a six-year follow-up. J Bone Joint Surg Am. 2014;96(17):1425–32.

    Article  CAS  PubMed  Google Scholar 

  12. Saragaglia D, Blaysat M, Inman D, Mercier N. Outcome of opening wedge high tibial osteotomy augmented with a Biosorb® wedge and fixed with a plate and screws in 124 patients with a mean of ten years follow-up. Int Orthop. 2011;35(8):1151–6.

    Article  PubMed  Google Scholar 

  13. Schallberger A, Jacobi M, Wahl P, Maestretti G, Jakob RP. High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13–21 years. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):122–7.

    Article  PubMed  Google Scholar 

  14. Kröner AH, Berger CE, Kluger R, Oberhauser G, Bock P, Engel A. Influence of high tibial osteotomy on bone marrow edema in the knee. Clin Orthop Relat Res. 2007;454:155–62.

    Article  PubMed  Google Scholar 

  15. Kim MS, Koh IJ, Sohn S, Sung HS, In Y. Degree of preoperative subchondral bone marrow lesion is associated with postoperative outcome after medial opening wedge high tibial osteotomy. Am J Sports Med. 2019;47(10):2454–63.

    Article  PubMed  Google Scholar 

  16. Kim MS, Koh IJ, Kim CK, Choi KY, Kang KH, In Y. Preoperative medial meniscal extrusion is associated with patient-reported outcomes after medial opening wedge high tibial osteotomy. Am J Sports Med. 2020;48(10):2376–86.

    Article  PubMed  Google Scholar 

  17. Lee CH, Yang HY, Seon JK. Increased medial meniscus extrusion led to worse clinical outcomes after medial opening-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2023;31(4):1614–22.

    Article  PubMed  Google Scholar 

  18. Hunter DJ, Guermazi A, Lo GH, Grainger AJ, Conaghan PG, Boudreau RM, Roemer FW. Evolution of semi-quantitative whole joint assessment of knee OA: MOAKS (MRI osteoarthritis knee score). Osteoarthritis Cartilage. 2011;19(8):990–1002.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Costa CR, Morrison WB, Carrino JA. Medial meniscus extrusion on knee MRI: is extent associated with severity of degeneration or type of tear? AJR Am J Roentgenol. 2004;183(1):17–23.

    Article  PubMed  Google Scholar 

  20. Anderson AF, Irrgang JJ, Dunn W, Beaufils P, Cohen M, Cole BJ, Coolican M, Ferretti M, Glenn RE Jr., Johnson R, Neyret P, Ochi M, Panarella L, Siebold R, Spindler KP, Ait Si Selmi T, Verdonk P, Verdonk R, Yasuda K, Kowalchuk DA. Interobserver reliability of the international society of arthroscopy, knee surgery and orthopaedic sports medicine (ISAKOS) classification of meniscal tears. Am J Sports Med. 2011;39(5):926–32.

    Article  PubMed  Google Scholar 

  21. McConnell S, Kolopack P, Davis AM. The Western Ontario and Mcmaster universities osteoarthritis index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum. 2001;45(5):453–61.

    Article  CAS  PubMed  Google Scholar 

  22. Aagaard H, Verdonk R. Function of the normal meniscus and consequences of meniscal resection. Scand J Med Sci Sports. 1999;9(3):134–40.

    Article  CAS  PubMed  Google Scholar 

  23. Jones RS, Keene GC, Learmonth DJ, Bickerstaff D, Nawana NS, Costi JJ, Pearcy MJ. Direct measurement of hoop strains in the intact and torn human medial meniscus. Clin Biomech (Bristol Avon). 1996;11(5):295–300.

    Article  Google Scholar 

  24. Lerer DB, Umans HR, Hu MX, Jones MH. The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion. Skeletal Radiol. 2004;33(10):569–74.

    Article  CAS  PubMed  Google Scholar 

  25. Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg Am. 2008;90(9):1922–31.

    Article  PubMed  Google Scholar 

  26. Badlani JT, Borrero C, Golla S, Harner CD, Irrgang JJ. The effects of meniscus injury on the development of knee osteoarthritis: data from the osteoarthritis initiative. Am J Sports Med. 2013;41(6):1238–44.

    Article  PubMed  Google Scholar 

  27. Roubille C, Raynauld JP, Abram F, Paiement P, Dorais M, Delorme P, Bessette L, Beaulieu AD, Martel-Pelletier J, Pelletier JP. The presence of meniscal lesions is a strong predictor of neuropathic pain in symptomatic knee osteoarthritis: a cross-sectional pilot study. Arthritis Res Ther. 2014;16(6):507.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Wenger A, Englund M, Wirth W, Hudelmaier M, Kwoh K, Eckstein F. Relationship of 3D meniscal morphology and position with knee pain in subjects with knee osteoarthritis: a pilot study. Eur Radiol. 2012;22(1):211–20.

    Article  PubMed  Google Scholar 

  29. Goto N, Okazaki K, Akiyama T, Akasaki Y, Mizu-Uchi H, Hamai S, Nakamura S, Nakashima Y. Alignment factors affecting the medial meniscus extrusion increases the risk of osteoarthritis development. Knee Surg Sports Traumatol Arthrosc. 2019;27(8):2617–23.

    Article  PubMed  Google Scholar 

  30. Ma X, Liu Q, Xu D. Biomechanical impact of progressive meniscal extrusion on the knee joint: a finite element analysis[J]. J Orthop Surg Res. 2024;19(1):1–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Xu T, Xu L, Li X, Zhou Y. Large medial meniscus extrusion and varus are poor prognostic factors of arthroscopic partial meniscectomy for degenerative medial meniscus lesions[J]. J Orthop Surg Res. 2022;17(1):1749–799.

    Article  Google Scholar 

  32. Jing L, Liu K, Wang X, et al. Second - look arthroscopic findings after medial open - wedge high tibial osteotomy combined with all - inside repair of medial meniscus posterior root tears[J]. J Orthop Surg. 2020;28(1):2309499019888836.

    Article  Google Scholar 

  33. Itou J, Kuwashima U, Itoh M, Okazaki K. High tibial osteotomy for medial meniscus posterior root tears in knees with moderate varus alignment can achieve favorable clinical outcomes[J]. J Experimental Orthop. 2022;9(1):65.

    Article  Google Scholar 

  34. Astur DC, Novaretti JV, Gomes ML, Rodrigues AG Jr., Kaleka CC, Cavalcante ELB, Debieux P, Amaro JT, Cohen M. Medial opening wedge high tibial osteotomy decreases medial meniscal extrusion and improves clinical outcomes and return to activity. Orthop J Sports Med. 2020;8(4):2325967120913531.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Yang HY, Kwak WK, Lee CH, Kang JK, Song EK, Seon JK. Extent of preoperative medial meniscal extrusion influences intermediate-term outcomes after medial opening-wedge high tibial osteotomy. J Bone Joint Surg Am. 2022;104(4):316–25.

    Article  PubMed  Google Scholar 

  36. Allen DM, Li L, Crema MD, Marra MD, Guermazi A, Wyman BT, Le Graverand MP, Englund M, Brandt KD, Hunter DJ. The relationship between meniscal tears and meniscal position. Ther Adv Musculoskelet Dis. 2010;2(6):315–23.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Kim SJ, Choi CH, Chun YM, Kim SH, Lee SK, Jang J, Jeong H, Jung M. Relationship between preoperative extrusion of the medial meniscus and surgical outcomes after partial meniscectomy. Am J Sports Med. 2017;45(8):1864–71.

    Article  PubMed  Google Scholar 

  38. Willinger L, Lang JJ, von Deimling C, Diermeier T, Petersen W, Imhoff AB, Burgkart R, Achtnich A. Varus alignment increases medial meniscus extrusion and peak contact pressure: a Biomechanical study. Knee Surg Sports Traumatol Arthrosc. 2020;28(4):1092–8.

    Article  PubMed  Google Scholar 

  39. Van Thiel GS, Frank RM, Gupta A. Biomechanical evaluation of a high tibial osteotomy with a meniscal transplant. J Knee Surg. 2011;24(1):45–53.

    Article  PubMed  Google Scholar 

  40. Villegas DF, Hansen TA, Liu DF, Donahue TL. A quantitative study of the microstructure and biochemistry of the medial meniscal Horn attachments. Ann Biomed Eng. 2008;36(1):123–31.

    Article  PubMed  Google Scholar 

  41. Hayes CW, Jamadar DA, Welch GW, Jannausch ML, Lachance LL, Capul DC, Sowers MR. Osteoarthritis of the knee: comparison of MR imaging findings with radiographic severity measurements and pain in middle-aged women. Radiology. 2005;237(3):998–1007.

    Article  PubMed  Google Scholar 

  42. Kornaat PR, Kloppenburg M, Sharma R, Botha-Scheepers SA, Le Graverand MP, Coene LN, Bloem JL, Watt I. Bone marrow edema-like lesions change in volume in the majority of patients with osteoarthritis; associations with clinical features. Eur Radiol. 2007;17(12):3073–8.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Brem MH, Schlechtweg PM, Bhagwat J, Genovese M, Dillingham MF, Yoshioka H, Lang P. Longitudinal evaluation of the occurrence of MRI-detectable bone marrow edema in osteoarthritis of the knee. Acta Radiol. 2008;49(9):1031–7.

    Article  CAS  PubMed  Google Scholar 

  44. Felson DT, Chaisson CE, Hill CL, Totterman SM, Gale ME, Skinner KM, Kazis L, Gale DR. The association of bone marrow lesions with pain in knee osteoarthritis. Ann Intern Med. 2001;134(7):541–9.

    Article  CAS  PubMed  Google Scholar 

  45. Sowers MF, Hayes C, Jamadar D, Capul D, Lachance L, Jannausch M, Welch G. Magnetic resonance-detected subchondral bone marrow and cartilage defect characteristics associated with pain and X-ray-defined knee osteoarthritis. Osteoarthritis Cartilage. 2003;11(6):387–93.

    Article  CAS  PubMed  Google Scholar 

  46. Ip S, Sayre EC, Guermazi A, Nicolaou S, Wong H, Thorne A, Singer J, Kopec JA, Esdaile JM, Cibere J. Frequency of bone marrow lesions and association with pain severity: results from a population-based symptomatic knee cohort. J Rheumatol. 2011;38(6):1079–85.

    Article  PubMed  Google Scholar 

  47. Zhai G, Blizzard L, Srikanth V, Ding C, Cooley H, Cicuttini F, Jones G. Correlates of knee pain in older adults: Tasmanian older adult cohort study. Arthritis Rheum. 2006;55(2):264–71.

    Article  PubMed  Google Scholar 

  48. Felson DT, McLaughlin S, Goggins J, LaValley MP, Gale ME, Totterman S, Li W, Hill C, Gale D. Bone marrow edema and its relation to progression of knee osteoarthritis. Ann Intern Med. 2003;139(5 Pt 1):330–6.

    Article  PubMed  Google Scholar 

  49. Sharkey PF, Cohen SB, Leinberry CF, Parvizi J. Subchondral bone marrow lesions associated with knee osteoarthritis. Am J Orthop (Belle Mead NJ). 2012;41(9):413–7.

    PubMed  Google Scholar 

  50. Martig S, Boisclair J, Konar M, Spreng D, Lang J. MRI characteristics and histology of bone marrow lesions in dogs with experimentally induced osteoarthritis. Vet Radiol Ultrasound. 2007;48(2):105–12.

    Article  PubMed  Google Scholar 

Download references

Funding

The present study was supported by grants from the Ningbo Natural Science Foundation Project (2021J020), the Zhejiang Provincial Health and Medicine Science and Technology Project (2022KY1170), and the Zhejiang Provincial Health and Medicine Science and Technology Project (2024KY1614).

Author information

Authors and Affiliations

  1. Department of Joint Surgery, Ningbo No. 6 Hospital, Ningbo, Zhejiang, P. R. China

    Haojun Zhang, Zhenglin Di & Ming Li

  2. Department of Orthopedic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P. R. China

    Hengzhi Liu

  3. Department of Joint Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P. R. China

    Lei Zhang

Authors
  1. Haojun Zhang
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Hengzhi Liu
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Lei Zhang
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Zhenglin Di
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Ming Li
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

Z. L. and D.wrote the main manuscript text and Z.L. prepared figures and tables. All authors reviewed the manuscript.

Corresponding author

Correspondence to Ming Li.

Ethics declarations

Ethics approval and consent to participate

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The ethical approval from the Hospital Ethics Committee was obtained for the study design (No. 2017009).

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, H., Liu, H., Zhang, L. et al. Influence of preoperative medial meniscus extrusion and subchondral bone marrow edema on outcomes after medial opening wedge high tibial osteotomy. J Orthop Surg Res 20, 353 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13018-025-05656-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13018-025-05656-9

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X