Summary

Limited conclusions regarding the optimum management strategy for MCD and ACLD can be derived due to the lack of controlled trials, but from the data that is available there is a statistically significant improvement in post-operative outcome scores following HTO in isolation and a combined procedure.

Abstract

Introduction

The purpose of this study was to conduct a systematic review and meta-analysis, where possible, of the literature reporting outcomes of anterior cruciate ligament deficient (ACLD) knees with medial compartment degeneration (MCD) treated with isolated high tibial osteotomy (HTO) or simultaneous HTO and anterior cruciate ligament reconstruction (ACLR).

Methods

The electronic databases MEDLINE, EMBASE, and Cochrane were searched for relevant studies and pertinent data was extracted. Studies published meeting the inclusion criteria following isolated HTO and simultaneous HTO and ACLR were included. Findings were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

The search identified 421 studies, of which 10 (n=273) met the inclusion criteria. No randomised trials were identified. All included studies reported survival rates and 9 studies reported subjective patient reported outcome measures. 174 patients underwent HTO and ACLR at an average follow-up of 51.2 (SD 21.1) months and demonstrated an improved subjective patient outcome across a variety of scoring systems. Lysholm and IKDC scores were the most widely used (4 studies, n=143). The pooled post-operative mean Lysholm score of 82.9 (95% CI: 66.4-99.3) improved from a pooled mean pre-operative score of 51.7 (95% CI: 40.7-62.8). There were 25 (21%) reported complications and 3 (2.1%) reported failures: 2 patients required revision surgery and 1 patient underwent total knee arthroplasty. Three studies described outcomes of patients who underwent isolated HTO in 128 patients with a mean follow-up of 88.6 (SD 48.7) months. Only one study reported pre- and post-operative outcomes scores meaning further statistical analysis was not possible. Four of the included ten studies, reported pre-operative grading of OA and any progression. Two studies reported statistically significant progression of OA following isolated HTO whilst 1 study reported statistically significant progression of OA following combined HTO and ACLR.

Conclusions

Limited conclusions regarding the optimum management strategy for MCD and ACLD can be derived due to the lack of controlled trials. Furthermore, this meta-analysis and systematic review has identified that the data available is of poor quality for both of these treatment strategies. From the data that is available, there is a statistically significant improvement in post-operative outcome scores following HTO in isolation and a combined procedure, although there continues to be progression of OA in both treatment groups. Consequently, clear indications for a combined procedure versus HTO in isolation can not be devised.