Double‐level osteotomy versus high tibial osteotomy for varus malalignment of the knee: A systematic review and meta‐analysis

Purpose To compare double‐level osteotomy (DLO) with high tibial osteotomy (HTO) for varus knee malalignment across patient‐reported, radiographic, operative and complication outcomes. Methods PubMed, Scopus and Web of Science were searched to 15 May 2026 for comparative DLO versus HTO studies. Outcomes were pooled with a random‐effects model as mean differences (MD) or risk ratios (RR) with 95% confidence intervals (CI), with absolute values for each arm. The primary outcome was joint‐line obliquity (JLO). Sensitivity analyses (leave‐one‐out, one cohort per centre, comparable indications) were post hoc. Results Nine observational studies (805 knees; 306 DLO, 499 HTO) were included. At a mean follow‐up of 3 years, postoperative JLO was lower after DLO than after HTO (four studies; 1.6° vs. 5.9°; MD: −4.14°, 95%CI: −5.22, −3.06; I 2 = 76%). DLO produced a lower MPTA (seven studies; 91.3° vs. 95.4°; MD: −4.10°, 95%CI: −5.30, −2.90), LDFA (four studies; 86.0° vs. 90.2°; MD: −4.04°, 95%CI: −4.49, −3.58) and mLDFA (two studies; 85.6° vs. 89.0°; MD: −3.37°, 95%CI: −4.16, −2.58). The hip‐knee‐ankle angle difference was small (five studies; MD: −0.96°, 95%CI: −1.83, −0.09) and not robust in sensitivity analyses. No difference was demonstrated for joint‐line convergence angle, posterior tibial slope, any KOOS subscale, KSS scores or time to return to sport. Operative time was longer with DLO (two studies; 137 vs. 91 min; MD: 42.9, 95%CI: 25.7, 60.2). Intraoperative hinge fracture was less frequent with DLO (three studies; 14.0% vs. 34.6%; RR: 0.41, 95%CI: 0.23, 0.73). No nonunion was reported. Conclusions At 3 years, no significant difference in patient‐reported or functional outcomes was demonstrated between DLO and HTO. DLO achieved correction with less JLO and fewer hinge fractures, at the cost of a longer operation. Because DLO was often selected for bifocal or larger deformities, the radiographic differences partly reflect the indication. These hypothesis‐generating findings require prospective confirmation. Level of Evidence Level I.