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



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.


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.


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.


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



High tibial osteotomy ACL ACL reconstruction Varus deformity Osteoarthritis 



Anterior cruciate ligament


Anterior cruciate ligament deficient


Anterior cruciate ligament reconstruction


American Knee Score




Closed wedge


Deep vein thrombosis


High tibial osteotomy


Intra-class correlation


International Knee Documentation Committee




Knee injury and osteoarthritis outcome score


Ligament augmentation device


Methodological Index for Non-Randomized Studies




Open wedge


Preferred Reporting Items for Systematic Review and Meta-Analysis


Posterior tibial slope


Total knee arthroplasty


Visual analogue score


Western Ontario and McMaster Osteoarthritis Index



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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