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Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction

  • Devon Stride
  • Julian Wang
  • Nolan S. Horner
  • Bashar Alolabi
  • Vickas Khanna
  • Moin KhanEmail author
KNEE

Abstract

Purpose

The purpose of this study was to systematically review the existing literature reporting surgical outcomes of simultaneous high tibial osteotomy (HTO) and anterior cruciate ligament reconstruction (ACLR) in anterior cruciate ligament deficient (ACLD) knees.

Methods

This study was conducted per the methods of the Cochrane Handbook for Systematic Reviews of Intervention, with findings reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data was extracted. Studies reporting post-operative outcomes following simultaneous HTO and ACLR in ACLD knees were included.

Results

The search identified 515 studies, of which 18 (n = 516) were included. The mean MINORS scores for non-comparative and comparative studies were 11.6 ± 1.34 and 17.3 ± 1.9, respectively. Simultaneous HTO and ACLR resulted in improved functional subjective patient outcomes across a variety of scales. Simultaneous HTO and ACLR was effective in correcting varus angulation, with the post-operative mechanical angle ranging from 0.3° valgus to 7.7° valgus. The reported complication rate ranged from 0 to 23.5%. Across six studies, a total of 13 (6.5%) patients required revision HTO; while across four studies, 20 (17.5%) patients had failure of the ACL graft, with one receiving revision ACLR.

Conclusions

Combined HTO and ACLR may be indicated in patients with ACLD knees with varus angulation. This systematic review found that the combined surgery resulted in significant improvement in post-operative functional subjective outcomes. However, it remains unclear if HTO with ACLR is superior to ALCR or HTO alone due to the lack of comparative studies. Overall, HTO with ACLR was found to have low rates of complications, re-ruptures, and need for revision surgery. This review found that patients continued to have progression of OA despite combined HTO with ACLR. Future research is required to better understand the effects of combined HTO and ACLR compared to ACLR or HTO alone and to evaluate the long-term post-operative progression of medial compartment OA following combined HTO and ACLR.

Level of evidence

IV.

Keywords

High tibial osteotomy ACL ACL reconstruction Varus deformity Osteoarthritis 

Abbreviations

ACL

Anterior cruciate ligament

ACLD

Anterior cruciate ligament deficient

ACLR

Anterior cruciate ligament reconstruction

AKS

American Knee Score

BPTB

Bone-patellar-tendon–bone

CW

Closed wedge

DVT

Deep vein thrombosis

HTO

High tibial osteotomy

ICC

Intra-class correlation

IKDC

International Knee Documentation Committee

KL

Kellen–Lawernce

KOOS

Knee injury and osteoarthritis outcome score

LAD

Ligament augmentation device

MINORS

Methodological Index for Non-Randomized Studies

OA

Osteoarthritis

OW

Open wedge

PRIMSA

Preferred Reporting Items for Systematic Review and Meta-Analysis

PTS

Posterior tibial slope

TKA

Total knee arthroplasty

VAS

Visual analogue score

WOMAC

Western Ontario and McMaster Osteoarthritis Index

Notes

Funding

No funding was received for the implementation of this study.

Compliance with ethical standards

Conflict of interest

The authors have reported no conflicts of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors thus ethics approval was not required.

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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonCanada
  2. 2.Division of Orthopaedic Surgery, Department of SurgeryMcMaster University Medical CentreHamiltonCanada

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