Simultaneous anterior cruciate ligament reconstruction with valgus high tibial osteotomy improves mid- to long-term clinical outcomes without increasing the complication rates in young anterior cruciate ligament deficient patients with varus malalignment: a systematic review and meta-analysis.

purposeThe purpose of this study is to systematically review and quantitatively analyze the mid- to long-term clinical outcomes of simultaneous anterior cruciate ligament reconstruction (ACLR) and valgus high tibial osteotomy (HTO) in the treatment of ACL injury with varus malalignment of the knee.

methodsThis study was performed in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) Guidelines. PubMed, Embase, and Web of Science databases were searched to identify studies reporting clinical outcomes of simultaneous ACLR and valgus HTO surgery. Data on follow-up duration, patient-reported outcome measures, clinical stability assessment, radiological outcomes, return to sports level evaluation, and complication rate were extracted. The Methodological Index for Non-Randomized Study scores was used for quality assessment. Review Manager and R statistical software were used to perform the statistical analysis.

resultsFifteen studies with a total of 463 knees in 461 patients were included. Patients were predominantly male (75%). After mid- to long-term follow-up, the weighted mean of mechanical femoral tibial angle (mFTA) increased from 174.6° to 182.0° (weighted mean difference = -7.4; p < 0.00001) after the simultaneous HTO and ACLR procedure. Significant improvements (p < 0.00001) were identified in the International Knee Documentation Committee (IKDC) subjective score (weighted mean: 51.8 vs. 69.7), Lysholm score (weighted mean: 59.8 vs. 87.3), and Tegner activity score (weighted mean: 3.5 vs. 4.8). The proportion of patients returned to pre-injury sports level ranged from 31.43% to 50% with an overall pooled rate of 31.8%. The incidence of complications ranged from 0% to 75% with an overall pooled risk of 13.4% (95% CI = 4.9%-25.2%). Two patients (0.46%) required revision surgery due to graft failure. Five studies compared the clinical outcomes of simultaneous valgus-producing HTO with ACLR and HTO alone procedures. The pooled analysis showed that the combined procedure group had a significantly higher Lysholm score (weighted mean: 72.4 vs. 78.7; WMD = -6.3; p = 0.02). As for the radiological anterior tibial translation (ATT) measurement (weighted mean: 3.50 vs. 2.26, p = 0.19), the Kellgren-Lawrence OA grading score (weighted mean: 0.47 vs. 0.32, p = 0.12) and the incidence of complications (10/49 [20.4%] vs. 9/47 [19.1%]; OR = 0.71; P = 0.75), no significant difference between combined procedure group and HTO alone group were found.

conclusionThis review showed that the simultaneous ACLR with valgus HTO could achieve improvement of clinical outcomes in terms of PROMs, knee stability, and return to pre-injury level. The indication of this procedure is physically active ACL-D patients with knee varus resulting from medial compartment OA and/or medial meniscus insufficiency, rather than ACL injury with constitutional knee varus. Compared with HTO alone, the combined procedure improved knee function, but did not reduce the incidence of radiological OA progression or complication risk. LEVEL OF EVIDENCE: Level IV.