The clinical Outcome of One-stage High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction. A Current Concept Systematic and Comprehensive Review



1 ATOS Private Hospital, Heidelberg, Germany

2 Orthopedic Research Center, Mashhad university of Medical Sciences, Mashhad, Iran

3 Orthopaedic Department, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece


Background: Patients with an anterior cruciate ligament-deficient varus-angulated knee may need not only an isolated high tibial osteotomy (HTO), but also an additional anterior cruciate ligament reconstruction (ACLR). A number of prospective clinical trials have been published considering the combination of HTO and ACL reconstruction. Our aim was to investigate whether one-stage combined HTO and ACL reconstruction is an effective, well-established technique with long-term results in the treatment of varus-angu lated knees with ACL deficiency.
Methods: A systematic review was conducted by two independent reviewers by searching the MEDLINE/PubMed and the Cochrane Database of Systematic Reviews. These databases were queried with the term ‘combined high tibial osteotomy anterior cruciate ligament reconstruction’ and ‘simultaneous high tibial osteotomy anterior cruciate ligament reconstruction’.
Results: From the initial 41 studies we finally chose and assessed 6 studies were eligible according to our inclusion-exclusion criteria. The vast majority of the patients were treated with hamstrings autograft (85.6% of the patients), whereas a small minority had a patellar Bone-to-Bone autograft (12.8% of the patients) and 3 patients received a patellar allograft. High tibial open wedge osteotomy was performed in 116 patients (57.4%) and closed wedge in 86 patients (42.6%). The mean pre-operative angle of the patients included in our review was 6.6º varus, while the mean final post-operative angle was found to be 1.3º valgus. All 6 studies illustrated improved post-operative IKDC with the use of one-stage HTO and ACLR, whereas the reoperation rate was very low.
Conclusion: Despite the lack of high quality studies, it seems that one-stage HTO and ACLR is a safe and effective procedure for treatment of patients suffering from symptomatic varus osteoarthritis in combination with anterior knee instability.
Level of evidence: II


Main Subjects

1. Coventry MB. Osteotomy of the upper portion of
the tibia for degenerative arthritis of the knee.
A preliminary report. J Bone Surg Am. 1965;
2. Amendola A, Bonasia DE. Results of HTO in medial
OA of the knee. In: Amendola A, Bellemans J, Bonnin
M, MacDonald S, Menetrey J, editors. Paris: Springer;
3. Insall JN, Joseph DM, Msika C. High tibial osteotomy
for varusgonarthrosis. A long-term follow-up study. J
Bone Joint Surg Am. 1984; 66(7):1040-8.
4. Amendola A, Bonasia DE. Results of high tibial
osteotomy: review of the literature. Int Orthop. 2010;
5. Akizuki S, Shibakawa A, Takizawa T, Yamazaki I,
Horiuchi H. The long-term outcome of high tibial
osteotomy: a ten- to 20-year follow-up. J Bone Joint
Surg Br. 2008; 90(5):592-6.
6. Sprenger TR, Doerzbacher JF. Tibial osteotomy for the
treatment of varus gonarthrosis: survival and failure
analysis to twenty-two years. J Bone Joint Surg Am.
2003; 85-A(3):469-74.
7. Griffin T, Rowden N, Morgan D, Atkinson R, Woodruff P,
Maddern G. Unicompartmental knee arthroplasty for
the treatment of unicompartmental OA: a systematic
study. ANZ J Surg. 2007; 77(4):214-21.
8. Sisto DJ, Blazina ME, Heskiaoff D, Hirsh LC.
Unicompartment arthroplasty for osteoarthrosis of
the knee. Clin Orthop Relat Res. 1993; 286(1):149-53.
9. Santoso MB, Wu L. Unicompartmental knee
arthroplasty, is it superior to high tibial osteotomy in
treating unicompartmental osteoarthritis? A metaanalysis
and systemic review. J Orthop Surg Res.
2017; 12(1):50.
10. Pfitzner T, Perka C, von Roth P. unicompartmental vs.
total knee arthroplasty for medial osteoarthritis. Z
Orthop Unfall. 2017; 155(5):527-33.
11. O’Neill DF, James SL. Valgus osteotomy with anterior
cruciate ligament laxity. Clin Orthop Relat Res. 1992;
12. Stein BE, Williams RJ 3rd, Wickiewicz TL. Arthritis
and osteotomies in anterior cruciate ligament
reconstruction. Orthop Clin North Am. 2003;
13. Lewek M, Rudolph K, Axe M, Snyder-Mackler L. The
effect of insufficient quadriceps strength on gait
after anterior cruciate ligament reconstruction. Clin
Biomech (Bristol, Avon). 2002; 17(1):56-63.
14. Webster KE, Feller JA, Wittwer JE. Longitudinal changes
in knee joint biomechanics during level walking
following anterior cruciate ligament reconstruction
surgery. Gait Posture. 2012; 36(2):167-71.
15. Kessler MA, Behrend H, Henz S, Stutz G, Rukavina
A, Kuster MS. Function, osteoarthritis and activity
after ACL-rupture: 11 years follow-up results of
conservative versus reconstructive treatment. Knee
Surg Sport Traumatol Arthrosc. 2008; 16(5):442-8.
16. McNamara I, Birmingham TB, Fowler PJ, Giffin JR. High
tibial osteotomy: evolution of research and clinical
applications--a Canadian experience. Knee Surg Sport
Traumatol Arthrosc. 2013; 21(1):23-31.
17. Giffin JR, Shannon FJ. The role of the high tibial
osteotomy in the unstable knee. Sport Med Arthrosc
Rev. 2007; 15(1):23-31.
18. Rudan JF, Simurda MA. High tibial osteotomy. A
prospective clinical and roentgenographic review.
Clin Orthop Relat Res. 1990; 255(1):251-6.
19. Dejour H, Neyret P, Boileau P, Donell ST. Anterior
cruciate reconstruction combined with valgus
tibial osteotomy. Clin Orthop Relat Res. 1994;
20. Marriott K, Birmingham TB, Kean CO, Hui C, Jenkyn
TR, Giffin JR. Five-year changes in gait biomechanics
after concomitant high tibial osteotomy and ACL
reconstruction in patients with medial knee
osteoarthritis. Am J Sport Med. 2015; 43(9):2277-85.
21. Bonin N, Ait Si Selmi T, Donell ST, Dejour H, Neyret
P. Anterior cruciate reconstruction combined with
valgus upper tibial osteotomy: 12 years follow-up.
Knee. 2004; 11(6):431-7.
22. Mehl J, Paul J, Feucht MJ, Bode G, Imhoff AB, Südkamp
NP, et al. ACL deficiency and varus osteoarthritis:
high tibial osteotomy alone or combined with ACL
reconstruction? Arch Orthop Trauma Surg. 2017;
23. Herman BV, Giffin JR. High tibial osteotomy in the ACLdeficient
knee with medial compartment osteoarthritis.
J Orthop Traumatol. 2016; 17(3):277-85.
24. Mancuso F, Hamilton TW, Kumar V, Murray DW,
Pandit H. Clinical outcome after UKA and HTO in ACL
deficiency: a systematic review. Knee Surg Sports
Traumatol Arthrosc. 2016; 24(1):112-22.
25. Li Y, Zhang H, Zhang J, Li X, Song G, Feng H. 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. 2015;
26. Schuster P, Schulz M, Richter J. Combined biplanar
high tibial osteotomy, anterior cruciate ligament
reconstruction, and abrasion/microfracture in
severe medial osteoarthritis of unstable varus knees.
Arthroscopy. 2016; 32(2):283-92.
27. Arun GR, Kumaraswamy V, Rajan D, Vinodh K, Singh
AK, Kumar P, et al. Long-term follow up of singlestage
anterior cruciate ligament reconstruction and
high tibial osteotomy and its relation with posterior
tibial slope. Arch Orthop Trauma Surg. 2016;
28. Vaishya R, Vijay V, Jha GK, Agarwal AK. 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. 2016; 7(4):265-71.
29. Trojani C, Elhor H, Carles M, Boileau P. Anterior
cruciate ligament reconstruction combined with
valgus high tibial osteotomy allows return to sports.
Orthop Traumatol Surg Res. 2014; 100(2):209-12.
30. Zaffagnini S, Bonanzinga T, Grassi A, Marcheggiani
Muccioli GM, Musiani C, Raggi F, et al. Combined ACL
reconstruction and closing-wedge HTO for varus
angulated ACL-deficient knees. Knee Surg Sports
Traumatol Arthrosc. 2013; 21(4):934-41.
31. Noyes FR, Schipplein OD, Andriacchi TP, Saddemi SR,
Weise M. The anterior cruciate ligament-deficient 
knee with varus alignment. An analysis of gait
adaptations and dynamic joint loadings. Am J Sport
Med. 1992; 20(6):707-16.
32. Shahpari O, FallahKezabi M, Kalati HH, Bagheri F,
Ebrahimzadeh MH. Clinical outcome of anatomical
transportal arthroscop-ic anterior cruciate ligament
reconstruction with hamstring tendon autograft.
Arch Bone Jt Surg. 2018; 6(2):130-9.
33. van de Pol GJ, Arnold MP, Verdonschot N, van Kampen
A. Varus alignment leads to increased forces in the
anterior cruciate ligament. Am J Sport Med. 2009;
34. Kean CO, Birmingham TB, Garland JS, Jenkyn TR,
Ivanova TD, Jones IC, et al. Moments and muscle
activity after high tibial osteotomy and anterior
cruciate ligament reconstruction. Med Sci Sports
Exerc. 2009; 41(3):612-9.