Slope-reducing tibial osteotomy combined with primary or revision ACL reconstruction improves knee stability and subjective function in patients with steep posterior tibial slope: a systematic review and meta-analysis.

PURPOSE: To systematically review and quantitatively analyze the clinical outcomes of slope-reducing tibial osteotomy combined with anterior cruciate ligament (ACL) reconstruction (ACLR) in patients with steep posterior tibial slope (PTS).

METHODS

This study was performed in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) Guidelines. PubMed, Embase, Web of Science, and Scopus databases were searched to identify studies reporting clinical outcomes of slope-reducing tibial osteotomy in ACL reconstruction patients with steep PTS. Data on patient-reported outcome measures, radiological parameters, knee stability as revealed by pivot shift grade, and knee anterior laxity and complications were extracted based on the inclusion criteria. The Methodological Index for Non-Randomized Study (MINORS) score was used for quality assessment. Review Manager and R statistical software were used to perform the statistical analysis.

RESULTS

Nine studies with a total of 227 knees in 91 primary and 136 revision ACLR patients were included. Nearly 60% of patients experienced ≥2 revision ACLR. In revision ACLR, the currently well-accepted indication for slope-reducing osteotomy is a slope >12° (measured on the short-segment radiographs). Primary ACLR patients with a more stringent slope (≥16°, measured on weight-bearing full-length radiographs), excessive anterior tibial translation (≥6 mm), or poor meniscus status may benefit from additional osteotomy. After combined procedures, substantial decreases were detected in the proportion of knees with pivot shift grades II-III [71/121 (58.7%) vs 19/121 (15.7%); OR = 23; P = 0.003] and side-to-side differential anterior laxity (weighted mean: 8.0 vs 1.9, weighted mean difference = 6.1, P   <  0.00001). Significant improvements ( P  < 0.00001) were identified in the Lysholm score (weighted mean: 47 vs 82.9) and International Knee Documentation Committee score (weighted mean: 39.3 vs 71.7). The incidence of adverse events after osteotomy ranged from 0% to 39.1% with an overall pooled rate of 10.6% (95% confidence interval = 0.5%-20.7%). Hardware discomfort and graft re-rupture with high-grade pivot shift were common complications. No patients experienced surgical site infection or bone nonunion.

CONCLUSION

Combined slope-reducing tibial osteotomy demonstrates significant improvements in both knee stability and patient-reported outcomes for revision ACLR. Similarly, primary ACLR patients with steep PTS, excessive anterior tibial translation, and poor meniscus status may derive clinical benefits from additional osteotomy.