Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 24, Issue 1, pp 112–122 | Cite as

Clinical outcome after UKA and HTO in ACL deficiency: a systematic review

  • Francesco Mancuso
  • Thomas W. Hamilton
  • Vijay Kumar
  • David W. Murray
  • Hemant PanditEmail author



In the treatment of medial osteoarthritis secondary to anterior cruciate ligament (ACL) injury there is no consensus about optimum treatment, with both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) being viable options. The aim of this review was to compare the outcomes of these treatments, both with or without ACL reconstruction.


EMBASE, MEDLINE and the Clinical Trials Registers were searched to identify relevant studies. Studies meeting pre-defined inclusion criteria were assessed independently by two researchers for methodological quality and data extracted.


Twenty-six studies involving 771 patients were identified for inclusion. No randomized controlled trials were identified. Seventeen studies reported outcomes following HTO and nine studies reported outcomes following UKA. HTO patients were significantly younger than those receiving UKA, and ACL reconstruction patients were younger than non-reconstructed patients. Treatment with HTO ACL reconstruction had the lowest revision rate (0.62/100 observed component years) but the highest rate of complications (4.61/100 observed component years). Too little data were available to test for differences in outcome between different surgical techniques or prosthesis designs.


Limited conclusions about the optimum treatment can be made due to the absence of controlled trials. In patients treated with HTO ACL reconstruction, the high complication rate likely outweighs its minimally superior survival. Outcomes following UKA ACL reconstruction are similar to outcomes for UKA in the ACL intact knee without any increase in complications. As such in patients meeting indications for UKA, UKA ACL reconstruction should be performed with further work required to identify the optimum treatment in other patient groups.

Level of evidence



Medial compartment osteoarthritis Anterior cruciate ligament deficiency Anterior cruciate ligament reconstruction High tibial osteotomy Unicompartmental knee arthroplasty 


  1. 1.
    Agneskirchner JD, Burkart A, Imhoff AB (2002) Axis deviation, cartilage damage and cruciate ligament rupture-concomitant interventions in replacement of the anterior cruciate ligament. Unfallchirurg 105:237–245PubMedCrossRefGoogle Scholar
  2. 2.
    Ajuied A, Wong F, Smith C, Norris M, Earnshaw P, Back D, Davies A (2014) Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med 42:2242–2252PubMedCrossRefGoogle Scholar
  3. 3.
    Akamatsu Y, Mitsugi N, Taki N, Takeuchi R, Saito T (2010) Simultaneous anterior cruciate ligament reconstruction and opening wedge high tibial osteotomy: report of four cases. Knee 17:114–118PubMedCrossRefGoogle Scholar
  4. 4.
    Badhe NP, Forster IW (2002) High tibial osteotomy in knee instability: the rationale of treatment and early results. Knee Surg Sports Traumatol Arthrosc 10:38–43PubMedCrossRefGoogle Scholar
  5. 5.
    Boissonneault A, Pandit H, Pegg E, Jenkins C, Gill HS, Dodd CA, Gibbons CL, Murray DW (2013) No difference in survivorship after unicompartmental knee arthroplasty with or without an intact anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 21:2480–2486PubMedCrossRefGoogle Scholar
  6. 6.
    Bonin N, Ait Si Selmi T, Donell ST, Dejour H, Neyret P (2004) Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 years follow-up. Knee 11:431–437PubMedCrossRefGoogle Scholar
  7. 7.
    Boss A, Stutz G, Oursin C, Gachter A (1995) Anterior cruciate ligament reconstruction combined with valgus tibial osteotomy (combined procedure). Knee Surg Sports Traumatol Arthrosc 3:187–191PubMedCrossRefGoogle Scholar
  8. 8.
    Briem K, Ramsey DK, Newcomb W, Rudolph KS, Snyder-Mackler L (2007) Effects of the amount of valgus correction for medial compartment knee osteoarthritis on clinical outcome, knee kinetics and muscle co-contraction after opening wedge high tibial osteotomy. J Orthop Res 25:311–318PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Christensen NO (1991) Unicompartmental prosthesis for gonarthrosis. A nine-year series of 575 knees from a Swedish hospital. Clin Orthop Relat Res 273:165–169PubMedGoogle Scholar
  10. 10.
    Dejour H, Neyret P, Boileau P, Donell ST (1994) Anterior cruciate reconstruction combined with valgus tibial osteotomy. Clin Orthop Relat Res 299:220–228PubMedGoogle Scholar
  11. 11.
    Demange MK, Camanho GL, Pecora JR, Gobbi RG, Tirico LE, da Mota e Albuquerque RF (2011) Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-wedge high tibial osteotomy: a report of eight cases. Knee 18:387–391PubMedCrossRefGoogle Scholar
  12. 12.
    Dervin GF, Conway AF, Thurston P (2007) Combined anterior cruciate ligament reconstruction and unicompartmental knee arthroplasty: surgical technique. Orthopedics 30:39–41PubMedGoogle Scholar
  13. 13.
    Engh GA, Ammeen DJ (2014) Unicondylar arthroplasty in knees with deficient anterior cruciate ligaments. Clin Orthop Relat Res 472:73–77PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Gaasbeek RD, Nicolaas L, Rijnberg WJ, van Loon CJ, van Kampen A (2010) Correction accuracy and collateral laxity in open versus closed wedge high tibial osteotomy. A one-year randomized controlled study. Int Orthop 34:201–207PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Garg A, Walker PS (1990) Prediction of total knee motion using a three-dimensional computer-graphics model. J Biomech 23:45–58PubMedCrossRefGoogle Scholar
  16. 16.
    Giger P, Bereiter H, Gachter A (1987) Replacement of the anterior cruciate ligament combined with valgization osteotomy of the tibia in incipient medial gonarthrosis with anterior cruciate ligament insufficiency. Z Orthop Ihre Grenzgeb 125:68–72PubMedCrossRefGoogle Scholar
  17. 17.
    Goodfellow JW, Kershaw CJ, Benson MK, O’Connor JJ (1988) The Oxford Knee for unicompartmental osteoarthritis. The first 103 cases. J Bone Joint Surg Br 70:692–701PubMedGoogle Scholar
  18. 18.
    Gulati A, Pandit H, Jenkins C, Chau R, Dodd CA, Murray DW (2009) The effect of leg alignment on the outcome of unicompartmental knee replacement. J Bone Joint Surg Br 91:469–474PubMedCrossRefGoogle Scholar
  19. 19.
    Harman MK, Markovich GD, Banks SA, Hodge WA (1998) Wear patterns on tibial plateaus from varus and valgus osteoarthritic knees. Clin Orthop Relat Res 352:149–158PubMedGoogle Scholar
  20. 20.
    Haviv B, Bronak S, Thein R, Kidron A (2012) Mid-term outcome of opening-wedge high tibial osteotomy for varus arthritic knees. Orthopedics 35:192–196Google Scholar
  21. 21.
    Hernigou P, Deschamps G (2004) Posterior slope of the tibial implant and the outcome of unicompartmental knee arthroplasty. J Bone Joint Surg Am 86:506–511PubMedGoogle Scholar
  22. 22.
    Hohmann E, Bryant A, Imhoff AB (2006) The effect of closed wedge high tibial osteotomy on tibial slope: a radiographic study. Knee Surg Sports Traumatol Arthrosc 14:454–459PubMedCrossRefGoogle Scholar
  23. 23.
    Hui C, Salmon LJ, Kok A, Williams HA, Hockers N, van der Tempel WM, Chana R, Pinczewski LA (2011) Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee. Am J Sports Med 39:64–70PubMedCrossRefGoogle Scholar
  24. 24.
    Krishnan SR, Randle R (2009) ACL reconstruction with unicondylar replacement in knee with functional instability and osteoarthritis. J Orthop Surg Res 4:43PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Labek G, Thaler M, Janda W, Agreiter M, Stockl B (2011) Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Joint Surg Br 93:293–297PubMedCrossRefGoogle Scholar
  26. 26.
    Lattermann C, Jakob RP (1996) High tibial osteotomy alone or combined with ligament reconstruction in anterior cruciate ligament-deficient knees. Knee Surg Sports Traumatol Arthrosc 4:32–38PubMedCrossRefGoogle Scholar
  27. 27.
    Lerat JL, Moyen B, Garin C, Mandrino A, Besse JL, Brunet-Guedj E (1993) Anterior laxity and internal arthritis of the knee. Results of the reconstruction of the anterior cruciate ligament associated with tibial osteotomy. Rev Chir Orthop Reparatrice Appar Mot 79:365–374PubMedGoogle Scholar
  28. 28.
    Murray DW, Pandit H, Weston-Simons JS, Jenkins C, Gill HS, Lombardi AV, Dodd CA, Berend KR (2013) Does body mass index affect the outcome of unicompartmental knee replacement? Knee 20:461–465PubMedCrossRefGoogle Scholar
  29. 29.
    Neuschwander DC, Drez D Jr, Paine RM (1993) Simultaneous high tibial osteotomy and ACL reconstruction for combined genu varum and symptomatic ACL tear. Orthopedics 16:679–684PubMedGoogle Scholar
  30. 30.
    Noyes FR, Barber-Westin SD, Hewett TE (2000) High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med 28:282–296PubMedGoogle Scholar
  31. 31.
    Noyes FR, Barber SD, Simon R (1993) High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees. A two- to seven-year follow-up study. Am J Sports Med 21:2–12PubMedCrossRefGoogle Scholar
  32. 32.
    O’Neill DF, James SL (1992) Valgus osteotomy with anterior cruciate ligament laxity. Clin Orthop Relat Res 278:153–159PubMedGoogle Scholar
  33. 33.
    Oiestad BE, Engebretsen L, Storheim K, Risberg MA (2009) Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med 37:1434–1443PubMedCrossRefGoogle Scholar
  34. 34.
    Pandit H, Beard DJ, Jenkins C, Kimstra Y, Thomas NP, Dodd CA, Murray DW (2006) Combined anterior cruciate reconstruction and Oxford unicompartmental knee arthroplasty. J Bone Joint Surg Br 88:887–892PubMedCrossRefGoogle Scholar
  35. 35.
    Pandit H, Jenkins C, Gill HS, Smith G, Price AJ, Dodd CA, Murray DW (2011) Unnecessary contraindications for mobile-bearing unicompartmental knee replacement. J Bone Joint Surg Br 93:622–628PubMedCrossRefGoogle Scholar
  36. 36.
    Rout R, McDonnell S, Hulley P, Jayadev C, Khan T, Carr A, Murray D, Gill H, Price A (2013) The pattern of cartilage damage in antero-medial osteoarthritis of the knee and its relationship to the anterior cruciate ligament. J Orthop Res 31:908–913PubMedCrossRefGoogle Scholar
  37. 37.
    Shelbourne KD, Benner RW (2007) Isolated anterior cruciate ligament reconstruction in the chronic ACL-deficient knee with degenerative medial arthrosis. J Knee Surg 20:216–222PubMedGoogle Scholar
  38. 38.
    Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716PubMedCrossRefGoogle Scholar
  39. 39.
    Smith TO, Hing CB, Davies L, Donell ST (2009) Fixed versus mobile bearing unicompartmental knee replacement: a meta-analysis. Orthop Traumatol Surg Res 95:599–605PubMedCrossRefGoogle Scholar
  40. 40.
    Suero EM, Citak M, Cross MB, Bosscher MR, Ranawat AS, Pearle AD (2012) Effects of tibial slope changes in the stability of fixed bearing medial unicompartmental arthroplasty in anterior cruciate ligament deficient knees. Knee 19:365–369PubMedCrossRefGoogle Scholar
  41. 41.
    Suomalainen P, Jarvela T, Paakkala A, Kannus P, Jarvinen M (2012) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 5-year results. Am J Sports Med 40:1511–1518PubMedCrossRefGoogle Scholar
  42. 42.
    Terzaghi C, Ferrari V, Legnani C, Albisetti W, Ventura A (2011) Combined anterior cruciate ligament reconstruction and unicompartmental knee arthroplasty. J Orthop Traumatol 12:1Google Scholar
  43. 43.
    Tinius M, Hepp P, Becker R (2012) Combined unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 20:81–87PubMedCrossRefGoogle Scholar
  44. 44.
    Weston-Simons JS, Pandit H, Jenkins C, Jackson WF, Price AJ, Gill HS, Dodd CA, Murray DW (2012) Outcome of combined unicompartmental knee replacement and combined or sequential anterior cruciate ligament reconstruction: a study of 52 cases with mean follow-up of five years. J Bone Joint Surg Br 94:1216–1220PubMedCrossRefGoogle Scholar
  45. 45.
    White SH, Ludkowski PF, Goodfellow JW (1991) Anteromedial osteoarthritis of the knee. J Bone Joint Surg Br 73:582–586PubMedGoogle Scholar
  46. 46.
    Williams RJ 3rd, Kelly BT, Wickiewicz TL, Altchek DW, Warren RF (2003) The short-term outcome of surgical treatment for painful varus arthritis in association with chronic ACL deficiency. J Knee Surg 16:9–16PubMedGoogle Scholar
  47. 47.
    Williams RJ 3rd, Wickiewicz TL, Warren RF (2000) Management of unicompartmental arthritis in the anterior cruciate ligament-deficient knee. Am J Sports Med 28:749–760PubMedGoogle Scholar
  48. 48.
    Zaffagnini S, Bonanzinga T, Grassi A, Muccioli GMM, Musiani C, Raggi F, Iacono F, Vaccari V, Marcacci M (2013) Combined ACL reconstruction and closing-wedge HTO for varus angulated ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc 21:934–941PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  • Francesco Mancuso
    • 1
  • Thomas W. Hamilton
    • 2
  • Vijay Kumar
    • 3
  • David W. Murray
    • 2
  • Hemant Pandit
    • 2
    Email author
  1. 1.Clinic of Orthopaedics and TraumatologyUniversity of UdineUdineItaly
  2. 2.Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)University of OxfordOxfordUK
  3. 3.All India Institute of Medical SciencesNew DelhiIndia

Personalised recommendations