Could anterior closed-wedge high tibial osteotomy be a viable option in patients with high posterior tibial slope who undergo anterior cruciate ligament reconstruction? A systematic review and meta-analysis

PURPOSE: This study aims to examine the clinical and radiological outcomes of patients who underwent ACL reconstruction (ACLR) combined with anterior closed-wedge high tibial osteotomy (ACW-HTO) for posterior tibial slope (PTS) reduction to investigate the efficacy of this procedure in improving anterior knee stability and preventing graft failure in primary and revision ACLR. METHODS: A literature search was conducted in six databases (PubMed, Embase, Medline, Web of Science, Cochrane, and Scopus). The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The initial screening identified 1246 studies. Each eligible clinical article was screened according to the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence (LoE), excluding clinical studies of LoE V. Quality assessment of the articles was performed using the ROBINS-I methodological evaluation. This systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO). For the outcomes that were possible to perform a meta-analysis, a p < 0.05 was considered statistically significant. RESULTS: Five clinical studies were included in the final analysis. A total of 110 patients were examined. Pre- and post-operative clinical and objective tests that assess anteroposterior knee stability, PTS, clinical scores, and data on surgical characteristics, complications, return to sports activity, and graft failure after ACLR were investigated. A meta-analysis was conducted using R software, version 4.1.3 (2022, R Core Team), for Lysholm score and PTS outcomes. A statistically significant improvement for both these clinical and radiological outcomes (p < 0.05) after the ACW-HTO surgical procedure was found. CONCLUSION: ACLR combined with ACW-HTO restores knee stability and function with satisfactory clinical and radiological outcomes in patients with an anterior cruciate ligament injury associated with a high PTS and seems to have a protective effect from further ruptures on the reconstructed ACL. LEVEL OF EVIDENCE: Level IV.