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Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

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.

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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

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Funding

No funding was received for the implementation of this study.

Author information

Authors and 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
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  2. Julian Wang
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  3. Nolan S. Horner
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  4. Bashar Alolabi
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  5. Vickas Khanna
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Correspondence to Moin Khan.

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Appendix

Appendix

See Tables 3, 4 and 5.

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

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

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