The history of knee osteotomy

When you understand the history, the present becomes clearer.


Hippocrates  (c. 460 – c. 370 BC) published images of a device he used to straighten legs, so we can consider that clinical osteotomy goes back in time all the way back at least to his era.

Closer to our own time several surgeons stand out, and in particular Barton and MacEwen.​

Barton (1794 - 1871) did some clever work, and introduced arthroplasty and corrective osteotomy for limb deformities.

In 1826 he published a case of an 'osteotomy to loosen up a flexion deformity of the hip and create pseudarthrosis which became also the first arthroplasty. There was no anaesthesia and no asepsis in his time.

But the real leader was MacEwen (1848 - 1924) who treated children in particular for deformity. He had worked as Lister's dresser, and learned from him the principles of surgical asepsis. MacEwen went on to do 835 osteotomies and was a true innovator and a really great man.


In the 1960s, pioneers Jackson and Waugh presented their work with six femoral and 8 high tibial osteotomies for lateral osteoarthritis, using very rudimentary fixation.​

In 1964 Gariepy did the first lateral closing wedge HTO - 22 cases in 11 patients, followed by Coventry using a stepped staple.

These procedures were used for a wide range of indications, and the results in general were poor, with loosening and loss of correction and a high complication rate.​ This was really at the beginning of my own training era - this was how my own colleagues were seeing osteotomy - no fixation required - just break the leg, straighten it, make it look straight, stick it in plaster, wedge the plaster if necessary and hope for the best. But the results were terrible. This is where many surgeons still think we are and that’s not right because actually we have moved on to a point where osteotomy is now an accurate science.


And osteotomy really seemed to die with the first knee replacement in 1968 - initially total knee replacement, then uni-replacement and bi-compartmental replacement. All of these are great operations but they are at the end game, at the end stage, particularly the total knee. Philip Loebenhoffer, who is one of the fathers of modern osteotomy and a truly great man and a good friend quotes that "a knee replacement involves the internal amputation of the knee joint", which is very true.​

THE CURRENT ERA (since 2000)

Beyond 2000 we have developed a whole new technique that really deserves its own name.

Giancarlo Puddu, Professor from Rome, introduced us to his group's novel technique for carrying out osteotomy from the inside of the knee. He developed the medial opening wedge, and the angle stable plate

And then we moved into an era where we could really start to think about patient selection and planning, surgical access and fixation, and ways in which we can get these patients going quicker.

to the 21st CENTURY

Osteotomy has really gone through three phases -

  • the historical era (pre 1940)
  • the modern early years (1940 - 2000)
  • beyond 2000

Transcript of intro video

Before and After - from the publications of MacEwen

Staple fixation

Knee replacement - total and unicompartmental


Osteotomy has moved on to consider -

  • patient selection and planning
  • double osteotomy
  • slope-changing osteotomy
  • complex osteotomy
  • minimally-invasive osteotomy

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