Leg length changes after high tibial and distal femoral osteotomy: a systematic review and meta-analysis

Post-osteotomy leg length discrepancy can lead to gait abnormalities, low back pain, and patient dissatisfaction. The mean leg length changes in patients undergoing osteotomy techniques have varied across studies. This systematic review and meta-analysis aimed to investigate leg length changes after high tibial osteotomy (Medial opening wedge (MOW HTO) or Lateral closing wedge (LCW HTO)) and distal femoral osteotomy (Lateral opening wedge (LOW DFO) or Medial closing wedge (MCW DFO)). We searched PubMed/Medline, Embase, Scopus, Google Scholar, Web of Science, Cochrane Library, and reference lists according to the PRISMA guidelines for relevant articles reporting changes in leg length after osteotomy surgery (regardless of osteotomy type), with no time limit up to October 13, 2025.Leg length was measured using full-length standing radiographs. Cochran Q and I² tests were used to assess heterogeneity between studies. Thirteen studies, including 855 patients (884 knees), were included. The pooled results showed that the mean changes in leg length after MOW and LCW HTO were 5.4(95% CI: 3.6, 7.19, I2:0%) and − 3.22(95%CI: -6.21,-0.23, I2:31.4%) mm, respectively. The pooled estimates of the results showed that the mean changes in leg length after LOW and MCW DFO were 2.4 (95% CI: -1.67, 6.47; I2: 0%) and 1.73 (95% CI: -2.36, 5.83; I2: 0%) mm, respectively, and this difference was not significant. Both MOW and LCW HTO techniques significantly changed leg length. The mean leg length change in MOW may be greater than in LCW HTO. In cases where significant correction is required, LCW HTO may be a more appropriate treatment option. The choice of technique should be made in consultation with the patient and physician. Leg length changes were similar in the LOW and MCW DFO techniques. Level III, meta-analysis of Level III studies.