Complications after anterior closing-wedge high tibial osteotomy in anterior cruciate ligament reconstruction: A state-of-the-art technical review.

PURPOSE: To provide a state-of-the-art technical review of complications associated with anterior closing-wedge high tibial osteotomy (ACWHTO) performed in the setting of anterior cruciate ligament reconstruction (ACLR). The review focuses on mechanisms, risk factors, prevention strategies and management principles rather than pooled complication-rate estimation.

METHODS

A targeted literature search was performed in PubMed/MEDLINE, Ovid and Scopus, supplemented by manual review of references from key clinical series, technical reports, biomechanical studies and systematic reviews. Publications addressing ACWHTO, slope-reducing tibial osteotomy, ACL-deficient knees, primary or revision ACLR, or technical aspects relevant to complication prevention were considered. Evidence was synthesized qualitatively. Clinical cohort data were distinguished from biomechanical studies, technical reports, systematic reviews and expert-opinion-based recommendations. Pooled complication rates were not calculated because of heterogeneity in indications, osteotomy techniques, fixation constructs, follow-up, reporting definitions and potential cohort overlap.

RESULTS

ACWHTO may be performed using supratubercle, transtubercle, infratubercle or retrotubercle techniques, each with distinct implications for sagittal correction, fixation strategy, tibial tunnel planning, patellar height, bone healing and complication risk. Reported overall complication rates ranged from 0% to 56.5%, although definitions varied substantially across studies. Reported or potential complications include hinge fracture, unintended coronal alignment modification, knee hyperextension or genu recurvatum, patellar height changes, over- or undercorrection of posterior tibial slope, delayed union or nonunion, ACLR failure, infection and hardware removal when symptomatic. Available evidence suggests favourable clinical and radiographic outcomes in appropriately selected patients, but complication reporting remains inconsistent, and secondary procedures are variably defined.

CONCLUSION

ACWHTO is an effective adjunctive procedure for selected patients undergoing ACLR in the presence of increased posterior tibial slope. However, its true safety profile remains difficult to define. Patient selection, individualized planning, precise hinge and wedge control and stable fixation are essential to minimize complications. Prospective studies with standardized complication definitions and stratified reporting are required.

LEVEL OF EVIDENCE: Level V.