Skip to main content

Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction

Knee Surgery, Sports Traumatology, Arthroscopy volume 27, pages 1320–1331 (2019)Cite this article

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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

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

References

  1. 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(2):114–118

    Article  PubMed  Google Scholar 

  2. Amendola A, Bonasia DE (2010) Results of high tibial osteotomy: review of the literature. Int Orthop 34(2):155–160

    Article  PubMed  Google Scholar 

  3. Arun GR, Kumaraswamy V, Rajan D, Vinodh K, Singh AK et al (2016) Long-term follow up of single-stage anterior cruciate ligament reconstruction and high tibial osteotomy and its relation with posterior tibial slope. Arch Orthop Trauma Surg 136(4):505–511

    Article  CAS  PubMed  Google Scholar 

  4. Bonin N, Ait Si Selmi T, Donell ST, Dejour H et al (2004) Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 Years follow-up. Knee 11(6):431–437

    Article  CAS  PubMed  Google Scholar 

  5. Brouwer GM, Van Tol AW, Bergink AP, Belo JN, Bernsen R et al (2007) Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum 56(4):1204–1211

    Article  CAS  PubMed  Google Scholar 

  6. Cantin O, Magnussen R, Corbi F, Servien E, Neyret P et al (2015) The role of high tibial osteotomy in the treatment of knee laxity: a comprehensive review. Knee Surg Sports Traumatol Arthrosc 23(10):3026–3037

    Article  CAS  PubMed  Google Scholar 

  7. Cerejo R, Dunlop DD, Cahue S, Channin D, Song J et al (2002) The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease. Arthritis Rheum 46(10):2632–2636

    Article  PubMed  Google Scholar 

  8. Dejour H, Neyret P, Boileau P, Donell ST (1994) Anterior cruciate reconstruction combined with valgus tibial osteotomy. Clin Orthop Relat Res 299:220–228

    Google Scholar 

  9. Dejour D, Saffarini M, Demey G, Baverel L (2015) Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc 23(10):2846–2852

    Article  PubMed  Google Scholar 

  10. Demange MK, Camanho GL, Pécora JR, Gobbi RG, Tirico LEP et al (2011) Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-wedge high tibial osteotomy: a report of eight cases. Knee 18(6):387–391

    Article  PubMed  Google Scholar 

  11. Ebied AM, Foda AAA (2017) Combined anterior cruciate ligament reconstruction and high tibial osteotomy in anterior cruciate ligament-deficient varus knees. J Orthop Trauma Rehabil 23:8–12

    Article  Google Scholar 

  12. Feucht M, Cotic M, Saier T, Minzlaff P, Plath J et al (2016) Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 24(1):201–207

    Article  PubMed  Google Scholar 

  13. Gupta A, Tejpal T, Shanmurgaraj A, Horner N, Simunovic N, Duong A, Ayeni OR (2018) Surgical techniques, outcomes, indications, and complications of simultaneous high tibial osteotomy and anterior cruciate ligament revision surgery: a systematic review. HSSJ. https://doi.org/10.1007/s11420-018-9630-8

    Article  Google Scholar 

  14. Higgins J, Green S (2011) Cochrane handbook for systematic reviews of interventions. Version 5. The Cochrane Collaboration

  15. Huizinga MR, Gorter J, Demmer A, Bierma-Zeinstra SMA, Brouwer RW (2017) Progression of medial compartmental osteoarthritis 2–8 years after lateral closing-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 25(12):3679–3686

    Article  CAS  PubMed  Google Scholar 

  16. Kean CO, Birmingham TB, Garland JS, Jenkyn JS, Ivanova TD et al (2009) Moments and muscle activity after high tibial osteotomy and anterior cruciate ligament reconstruction. Med Sci Sports Exerc 41(3):612–619

    Article  PubMed  Google Scholar 

  17. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. 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(1):32–38

    Article  CAS  PubMed  Google Scholar 

  19. Li Y, Zhang H, Zhang J, Li X, Song G et al (2015) Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in young patients with anterior cruciate ligament–deficient knees: a systematic review. Arthroscopy 31(3):507–519

    Article  PubMed  Google Scholar 

  20. Malahias MA, Shahpari O, Kaseta MK (2018) The clinical outcome of one-stage high tibial osteotomy and anterior cruciate ligament reconstruction. A current concept systematic and comprehensive review. Arch Bone Jt Surg 6(3):161–168

    PubMed Central  PubMed  Google Scholar 

  21. Marriott K, Birmingham TB, Kean CO, Hui C, Jenkyn TR et al (2015) Five-year changes in gait biomechanics after concomitant high tibial osteotomy and ACL reconstruction in patients with medial knee osteoarthritis. Am J Sports Med 43(9):2277–2285

    Article  PubMed  Google Scholar 

  22. Mehl J, Paul J, Feucht MJ, Bode G, Imhoff AB et al (2017) ACL deficiency and varus osteoarthritis: high tibial osteotomy alone or combined with ACL reconstruction? Arch Orthop Trauma Surg 137(2):233–240

    Article  PubMed  Google Scholar 

  23. Moher D, Liberati A, Tetzlaff J, Altman D (2009) The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Ann Intern Med 151(4):264–269

    Article  PubMed  Google Scholar 

  24. Noyes FR, Barber SD, Simon R (1993) High tibial osteotomy and ligament reconstructions in varus angulated, anterior cruciate ligament-deficient knees: a two- to seven-year follow-up study. Am J Sports Med 21(1):2–12

    Article  CAS  PubMed  Google Scholar 

  25. O’Neill DF, James SL (1992) Valgus osteotomy with anterior cruciate ligament laxity. Clin Orthop Relat Res 278:153–159

    Article  Google Scholar 

  26. Schuster P, Schulz M, Richter J (2016) Combined biplanar high tibial osteotomy, anterior cruciate ligament reconstruction, and abrasion/microfracture in severe medial osteoarthritis of unstable varus knees. Arthroscopy 32(2):283–292

    Article  PubMed  Google Scholar 

  27. Sharma L, Song J, DT F, Cahue S, Shamiyeh E et al (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA 286(2):188–195

    Article  CAS  PubMed  Google Scholar 

  28. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y et al (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73(9):712–716

    Article  PubMed  Google Scholar 

  29. Stutz G, Boss AGA (1996) Comparison of augmented and non-augmented anterior cruciate ligament reconstruction combined with high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 4(3):143–148

    Article  CAS  PubMed  Google Scholar 

  30. Trojani C, Elhor H, Carles M, Boileau P (2014) Anterior cruciate ligament reconstruction combined with valgus high tibial osteotomy allows return to sports. Orthop Traumatol Surg Res 2014;100(2):209–212

    Article  CAS  PubMed  Google Scholar 

  31. Vaishya R, Agarwal AK, Ingole S, Vijay V (2015) Current trends in anterior cruciate ligament reconstruction: a review. Cureus 7(11):e378

    PubMed Central  PubMed  Google Scholar 

  32. Vaishya R, Vijay V, Jha GK, Agarwal AK (2016) Prospective study of the anterior cruciate ligament reconstruction associated with high tibial opening wedge osteotomy in knee arthritis associated with instability. J Clin Orthop Trauma 7(4):265–271

    Article  PubMed Central  PubMed  Google Scholar 

  33. Virolainen P, Aro HT (2004) High tibial osteotomy for the treatment of osteoarthritis of the knee: a review of the literature and a meta-analysis of follow-up studies. Arch Orthop Trauma Surg 124(4):258–261

    Article  PubMed  Google Scholar 

  34. 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(1):9–16

    PubMed  Google Scholar 

  35. Willey M, Wolf BR, Kocaglu B, Amendola A (2010) Complications associated with realignment osteotomy of the knee performed simultaneously with additional reconstructive procedure. Iowa Orthop J 30:55–60

    PubMed Central  PubMed  Google Scholar 

  36. Zaffagnini S, Bonanzinga T, Grassi A, Marcheggiani M, Giulio M et al (2013) Combined ACL reconstruction and closing-wedge HTO for varus angulated ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc 21(4):934–941

    Article  PubMed  Google Scholar 

Download references

Funding

No funding was received for the implementation of this study.

Author information

Affiliations

  1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

    Devon Stride & Julian Wang

  2. Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada

    Nolan S. Horner, Bashar Alolabi, Vickas Khanna & Moin Khan

Authors
  1. Devon Stride
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Julian Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nolan S. Horner
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Bashar Alolabi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vickas Khanna
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Moin Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Moin Khan.

Ethics declarations

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.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix

Appendix

See Tables 3, 4 and 5.

Table 3 Search Strategy
Full size table
Table 4 Study characteristics of included studies
Full size table
Table 5 Summary of included non-comparative studies: post-operative outcomes
Full size table

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Stride, D., Wang, J., Horner, N.S. et al. Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27, 1320–1331 (2019). https://doi.org/10.1007/s00167-019-05379-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-019-05379-5

Keywords

  • High tibial osteotomy
  • ACL
  • ACL reconstruction
  • Varus deformity
  • Osteoarthritis