Medial opening-wedge high tibial osteotomy (MOWHTO) is a powerful tool in the surgical armamentarium to correct varus malalignment in patients with symptomatic medial compartment disease. This procedure has demonstrated proven results and long-term survivorship. Complications include cortical hinge fracture, symptomatic hardware, infection, delayed or nonunion, and nerve injury. Varus recurrence is a known complication after MOWHTO. Risk factors are multifactorial and thought to include degree of alignment correction, extent of meniscus and cartilage pathology, and effectiveness of soft-tissue balancing. Medial meniscus extrusion has been implicated in meniscus dysfunction and progression of degenerative joint disease. It is a recognized issue after meniscus-preserving and transplant procedures that may have long-term sequela. This loss of hoop stress can lead to increased contact pressure, putting the diseased compartment at further risk. Although it is certainly possible that extrusion matters for varus recurrence after MOWHTO, its role must be considered in the context of multiple other confounding factors.