Most patients return to sports activities after knee osteotomy, with a tendency to lower-impact sports, and most patients return to work at the same or an even higher workload. |
Systematic comparison of current literature is hampered by heterogeneity in patient populations, operative techniques, and the overall lack of accounting for possible confounding factors such as physical and mental comorbidities, preoperative sports level and work status, patient motivation, and surgeon’s advice. |
Future prospective studies are needed to gain better insight into the reasons patients do not return to sport or work. These studies should correct for confounders and use the pre-symptomatic phase as a reference point when assessing return to sport and work. |
1 Introduction
2 Methods
2.1 Search Strategy
2.2 Eligibility Criteria and Study Selection
2.3 Methodological Quality
Study details, design, population [language] | Operation type (+fixation implant) | Rehabilitation protocol | Outcome measures | Preoperative activity + definition | Postoperative activity | RTS + time to RTS | RTW + time to RTW | Confounding factors |
---|---|---|---|---|---|---|---|---|
Study: Ampollini et al. [42], 1998, Italy [Italian] Design: ret cs, FU NS Population: Pts with chronic anterior laxity and varus malalignment (n = 7); age range 24–35; sex 7 M (100%); BMI NS; Co NS | LCW HTO + ACL reconstruction Fixation: plate 5; staples 2 | Knee brace for 60 days. CPM from postoperative d3 | Sports participation, n(%) | 0 Definition of pre-op: <1 year before surgery | 7 | >100%; time to RTS unknown | Unknown | Mentioned, not adjusted for: surgeon’s advice (RTS is not the goal); pre-injury sports level |
Study: Bode et al. [25], 2015, Germany Design: ret cohort study, FU: 5.0 ± 0.2 years Population: Pts with cartilage defect medial femoral condyle and varus malalignment >2º (n = 40); age 37.6 ± 7.5; sex NS; BMI 25.4 ± 3.4; Co NS | MOW HTO + ACI Fixation: TomoFix | CPM for 6 weeks, up to 4 h/day. Mobilization on postoperative d1. Limited weight bearing for 6 weeks | Lysholm | 54.4 ± 18.9 | 76.2 ± 19.8 (p < 0.01) | Unknown | % RTW: unknown Time to RTW: 94.5 ± 77.0 days REFA 1: 68.1 ± 61.4 days REFA 4: 155.0 ± 111.0 days(p = 0.023) | Adjusted for in analysis: BMI (>35 not included); workload. Mentioned, not adjusted for: age |
Workload: REFA work (physical strain, n(%)) | ||||||||
0 (without) | – | 11 | ||||||
1 (small) | – | 9 | ||||||
2 (moderate) | – | 5 | ||||||
3–4 (hard, most heavy) | – | 14 | ||||||
Definition of pre-op: unknown | ||||||||
Study: Bonnin et al. [43], 2013, France Design: ret, mc (four centers) cohort study; FU 4.2 ± 0.9 years Population: Pts with medial compartment OA and varus malalignment (n = 139); age 59.1 (range 24–80); sex 98 M (71%), 41 F (29%); BMI 27.2 ± 4.1; Co: medical limitation (respiratory, cardiac or neurologic): 6 | LCW HTO (n = 88) MOW HTO (n = 51) Fixation: plate 114, blade plate + screws 18, staples 7 | NS | Sports participation, n(%) | 29 (20.8%) more active, 62 (44.6%) same activity level, 45 (33%) less active than before surgery. Time to RTS unknown | Unknown | Adjusted for in analysis: age; motivation. Mentioned, not adjusted for: reasons for no RTS | ||
Stationary cycling | – | 38 | ||||||
Road cycling | – | 58 | ||||||
Stretching | – | 54 | ||||||
Swimming | – | 31 | ||||||
Golfing | – | 7 | ||||||
Sailing | – | 6 | ||||||
Strength exercise | – | 22 | ||||||
Dancing | – | 10 | ||||||
Gymnastics | – | 29 | ||||||
Hiking | – | 60 | ||||||
Gardening | – | 71 | ||||||
C-C skiing | – | 14 | ||||||
DH skiing | – | 35 | ||||||
Tennis | – | 2 | ||||||
Running >500 m | – | 6 | ||||||
Mean Weiss activity score | 5.3 ± 1.2 | |||||||
Light | – | 5.9 | ||||||
Intermediate | – | 5.5 | ||||||
Strenuous | – | 5.1 | ||||||
Definition of pre-op: before surgery | ||||||||
Study: Boss et al. [44], 1995, Switzerland Design: ret cohort study; FU 6.3 years (range 2.6–13.8) Population: Pts with ACL deficiency, existing cartilaginous lesions medial compartment ± medial meniscus lesion (n = 20), and varus malalignment (n = 27); age 36 (range 19–55); sex 22 M (82%), 5 F (18%); BMI NS; Co NS | ACL reconstruction (BPTB ± LAD, n = 13) + HTO (24 LCW, 3 MOW) Fixation: staples, AO-T-plates: semi-tubular plate with long screw in ventral tibial cortex | Dorsal cast and removable circular splint. Immediate passive ROM, early mobilization. Full weight bearing. At 3 months cycling and jogging allowed, at 6–9 months more demanding sports | Activity level | Unknown. Definition of pre-op: pre-trauma and pre-surgery | 55% higher at FU than preoperatively 15% lower at FU than preoperatively | 94%; 85% returned to same or higher level. Time to RTS unknown | 89% had returned to same profession at FU. Time to RTW unknown | Mentioned, not adjusted for: concomitant surgery |
Study: Boussaton et al. [41], 2007, France [French] Design: ret cs; FU NS (range 1–10 years) Population: Professional rugby players requiring HTO (n = 6); age NS; sex 6 M (100%); BMI NS; Co NS | Valgising HTO (n = 4) and varising HTO (n = 2) Fixation NS | NS | IKDC | Unknown. Definition of pre-op: pretraumatic | 94 (range 86–99) | 100% (6/6). Time to RTS unknown | Unknown | NS |
Study: Cotic et al. [45], 2015, Germany Design: pro cohort study; FU: 2 years Population: Pts with medial compartment OA and varus malalignment or medial compartment overload combined with localized chondral defects requiring cartilage repair (n = 28); age 45 (±11); sex 19 M (70%), 9 F (30%); BMI 25 ± 3; Co NS | (Biplanar) MOW HTO Fixation: second-generation peek-carbon composite plate Concomitant procedures: medial meniscectomy 5, microfracturing 1, OATS 6, ACL reconstruction 1 | Active and passive FROM as tolerated directly or after 6 weeks (in microfracture and OATS pts). 20-kg partial weight bearing until 6 weeks, then full weight bearing was allowed | Lysholm (n = 27) | 51 (40–62) | 83 (73–94) (p < 0.001) | >100% | Unknown | Mentioned, not adjusted for: fixation type; timing of implant removal |
Tegner (n = 27) | 5 (3–6) | 4 (3–5) (n.s.) | Time to RTS unknown | |||||
Sports participation, n(%) | RTS (%) | |||||||
Overall | 24 | 27 | >100 | |||||
Windsurfing | 1 | 1 | 100 | |||||
Sailing | 1 | 2 | >100 | |||||
Dancing | 4 | 4 | 100 | |||||
Martial arts | 1 | 1 | 100 | |||||
Basketball | 2 | 1 | 50 | |||||
Soccer | 2 | 0 | 0 | |||||
Bowling | 1 | 1 | 100 | |||||
Badminton | 3 | 0 | 0 | |||||
Table tennis | 2 | 2 | 100 | |||||
Tennis singles | 3 | 0 | 0 | |||||
Golf | 1 | 2 | >100 | |||||
Hunting | 2 | 1 | 50 | |||||
Ice skating | 1 | 1 | 100 | |||||
Snowboarding | 1 | 0 | 0 | |||||
C-C skiing | 7 | 6 | 86 | |||||
Downhill skiing | 5 | 8 | >100 | |||||
Aqua fit | 0 | 1 | >100 | |||||
Gymnastics | 4 | 5 | >100 | |||||
Aerobics | 1 | 0 | 0 | |||||
Fitness training | 9 | 15 | >100 | |||||
Swimming | 13 | 14 | >100 | |||||
Mountain biking | 6 | 7 | >100 | |||||
Cycling | 19 | 24 | >100 | |||||
Climbing | 3 | 3 | 100 | |||||
Hiking | 10 | 12 | >100 | |||||
Inline skating | 2 | 3 | >100 | |||||
Jogging | 6 | 7 | >100 | |||||
Nordic walking | 5 | 9 | >100 | |||||
Definition of pre-op: regular participation in year before surgery | ||||||||
Study: Dahl et al. [40], 2015, Sweden Design: pro cohort study; FU 10 years Population: Pts with unicompartmental knee OA treated with hemicallotasis HTO technique (medial OA 40; lateral OA 5) (n = 45); age 55 (range 35–64); sex 31 M (69%), 14 F (31%); BMI 29 ± 4.5; Co NS | HTO by hemicallotasis technique Fixation: external fixator | Free mobilization allowed. Full weight bearing. PT prescribed individually and related to needs of pt | Level of physical activity, n(%) (lifetime/pre-op): | 63% RTS (%) | At 2 years: 84%. At 10 years: 49% | Mentioned, not adjusted for: BMI; expectations; pts converted to TKA were excluded from FU; retirement | ||
6: competitive sports | 19/0 | 0 | 0 | |||||
5: recreational sports | 9/1 | 3 | 33 | |||||
4: golf, dancing, hiking, water aerobics | 10/9 | 21 | >100 | |||||
3: heavy yard/household work | 7/33 | 6 | 86 | |||||
2: light yard/household work | 0/2 | 13 | >100 | |||||
1: minimal household work, sewing, card games | 0/0 | 1 | – | |||||
0: no household work, TV/reading only | 0/0 | 1 | – | |||||
Working pts, n(%) | Time to RTS: unknown | |||||||
Working | 43 | 21 | ||||||
Retired | 2 | 23 | ||||||
Unemployed | 0 | 0 | ||||||
Sick leave | 0 | 1 | ||||||
Definition of pre-op: lifetime and pre-op | ||||||||
Study: De Carvalho et al. [38], 2012, Brazil Design: Cross-sectional cohort study; FU 4 years (range 1.7–9.5) Population: Pts with lateral compartment OA and valgus malalignment (n = 26); age 48.6 (range 21–65); sex 8 M (31%), 18 F (69%); BMI NS (<35 kg/m2); Co NS | LCW DFO Fixation: dynamic condylar screw (Synthes) | FROM as tolerated without weight bearing. Partial weight bearing after 6 weeks and full 8–12 weeks. RTS after healing of osteotomy and recovery of muscle strength | Sports participation, n(%) | 89% RTS (%) | 88.5% resumed normal work duties at pre-op functional level. Time to RTW: unknown | Mentioned, not adjusted for: age; limited FU; pre-op sports level; surgical technique | ||
Routine physical activity | 15 | 14 | 93 | |||||
Soccer | 3 | 3 | 100 | |||||
Volleyball | 1 | 0 | 0 | |||||
Tegner | 3 (2–7) | 3 (1–7) (n.s.) | ||||||
Lysholm | 53.1 ± 16.2 (24–95) Definition of pre-op: unknown | 77.3 ± 16.7 (29–100) (p < 0.001) | Time to RTS unknown | |||||
Study: Dejour et al. [46], 1994, France Design: ret cohort study; FU 3.6 years (range 1–11) Population: Pts with symptomatic chronic ACL deficiency + acquired varus malalignment (n = 44); age 29 (range 18–42); sex 27 M (63%), 16 F (37%); BMI NS; Co NS | ACL reconstruction (BPTB ± LET n = 34) + HTO (LCW n = 37; MOW n = 7) Fixation: two staples | Immediate ROM as tolerated. Non-weight bearing for 8 weeks | Sporting level (pre-injury/pre-surgery, n(%)) | 66% RTS (%) | Unknown | Adjusted for in analysis: no differences in RTS between pts with poor outcome and pts with good outcome | ||
Pivotal contact (e.g. soccer) | 30/17 | 7 | 23/41 | |||||
Pivotal non-contact (e.g. tennis) | 8/4 | 10 | >100 | |||||
Non-pivotal non-contact (e.g. cycling) | 3/4 | 10 | >100 | |||||
Definition of pre-op: both pre-injury and pre-surgery | Time to RTS unknown | |||||||
Study: Fasching-bauer et al. [47], 2015, Germany Design: Cross-sectional cohort study; FU 1.8 years ± 0.8 Population: Pts with medial compartment OA and varus malalignment (n = 43); age 42 ± 11.2; sex 32 M (74%), 11 F (26%); BMI 26.9 ± 3.6; Co NS; concomitant procedures: 13 (OATS 6; partial meniscectomy 4; microfracturing 3) | MOW HTO Fixation: TomoFix | 20-kg partial weight-bearing for 2 weeks, swiftly increased from week 2 until full weight bearing. Daily PT was recommended | General sports participation (at least 1 sport) | 39/43 (90.7%) | 36/43 (83.7%) | 92% (no inactive pts started new activities post-op) | 94% returned to pre-op workload. Time to RTW: 16.7 ± 15.6 weeks. Group I (high work intensity, n = 13): 19.1 ± 9.1 weeks. Group II (moderate, n = 12): 20 ± 17.8 weeks. Group III (low, n = 15): 11.8 ± 7.8 weeks (p = 0.325). No pre- and postoperative changes among groups | Adjusted for in analysis: analgesic use; completion of rehabilitation, cessation of partial weight bearing, workload. Mentioned, not adjusted for: avoidance of potentially harmful activities, limited FU, surgeon’s advice |
Sports activities n(%): | RTS (%) | |||||||
Cycling | 33 | 25 | 76% | |||||
Hiking | 19 | 16 | 84% | |||||
Swimming | 18 | 17 | 94% | |||||
Fitness | 8 | 10 | > 100% | |||||
Downhill skiing | 10 | 5 | 50% | |||||
Nordic walking | 8 | 6 | 75% | |||||
Jogging | 8 | 4 | 50% | |||||
Soccer | 8 | 2 | 25% | |||||
Gymnastics | 5 | 4 | 80% | |||||
Inline skating | 6 | 2 | 33% | |||||
Tegner | 3.78 ± 1.9 | 3.7 ± 1.4 (n.s.) | ||||||
Lysholm | Unknown | 68.7 ± 23.9 | Time to RTS unknown | |||||
Definition of pre-op: pre-symptomatic | ||||||||
Study: Gomoll et al. [36], 2009, USA Design: ret study; FU 2 years (range 1–4.2) Population: Pts with ipsilateral chondral defects and meniscal deficiency (n = 7); age 32 (range 18–43); sex 5 M (71%), 2 F (29%); BMI NS; Co NS | Meniscus allograft transplantation + cartilage repair + osteotomy: HTO 5, DFO 2 Fixation: NS | Hinged knee brace with CPM for 6 h/day for 6 weeks. Non-weight bearing 6 weeks. ADL activities after 3 months, return to non-contact sports after 4–5 months. No restrictions after 12 months | Lysholm (mean) | 34 | 77 (p < 0.01) | 100%, 6 to full activities without restrictions, 1 with mild symptoms while playing basketball. Time to RTS unknown | Unknown | Mentioned, not adjusted for: expectation management by surgeon |
IKDC | 26 Definition of pre-op: unknown (presumably pre-injury) | 63 (p < 0.01) | ||||||
Study: Hoell et al. [34], 2005, Germany Design: ret cohort study; FU 1.9 years (range 0.7–2.8) Population: Pts with medial compartment OA and varus malalignment treated with MOW HTO [(n = 40); age 46.4 ± 8; sex 25 M (63%), 15 F (37%); BMI 30 ± 5.2] or LCW HTO [(n = 51); age 52.1 ± 8.4; sex 36 M (70%), 15 F (30%); BMI 29 ± 4.2]; Co: no pts with rheumatic disease | MOW HTO n = 40; LCW HTO n = 51 Fixation: MOW: Puddu plate; LCW: staples | Limited ROM (0–0–90°) first 6 weeks | Lysholm (range) | Unknown. Time to RTS unknown | RTW unknown. Time to RTW: MOW: 13.9 weeks; LCW: 13.6 weeks (p = n.s.) | Adjusted for in analysis: type of osteotomy. Mentioned, not adjusted for: fixation type (Puddu plate, with pain at implant site); rehabilitation | ||
MOW | 46 (25–65) | 68 (45–92) (p < 0.05) | ||||||
LCW | 42 (19–63) | 63 (38–90) (p < 0.05) | ||||||
Tegner (range) | ||||||||
MOW | 3.2 (1.5–5) | 4.3 (2.6–6) (p < 0.05) | ||||||
LCW | 3.1 (1–5.2) Definition of pre-op: unknown | 3.9 (2.5–5.5) (p < 0.05) | ||||||
Study: Isolauri et al. [37], 1983, Finland Design: ret cohort study; FU 3 years (range 1–5) Population: Pts with unicompartmental knee OA and malalignment (n = 50: varus 32, valgus 18); age at operation 58 (range 33–77); sex 15 M (30%), 35 F (70%); BMI NS; Co: n = 26 (RA 1; HT 11; cardiac 8; diabetes 3; hyperthyroid 2; epilepsy 1) | HTO: LCW 32, MCW: 18 Fixation: Charnley’s compression device 16, plaster 34 (8 weeks) | Mobilization on crutches postoperative d1. Full weight bearing allowed after 3–4 weeks | – | – | – | Unknown Time to RTS: unknown | 41%. Time to RTW: 5.5 months (2.5–11 months). Working capacity at FU: return to previous work 10 of 12 (83%). Trained for new occupation 2 of 12 (17%) Disabled on account of knee OA 13 (26%) Disabled on account other disease 4 (8%) Pension 21 (42%) | Adjusted for in analysis: obtained correction. Mentioned, not adjusted for: co; reasons other than HTO for no RTW |
Study: Korovessis et al. [39], 1999, Greece Design: pro; FU 11 years (range 10–12) Population: Pts with medial compartment OA and varus malalignment who were employed in agriculture. Group I: n = 35; age 60 (range 49–74); sex 7 M (20%), 28 F (80%); BMI NS; Co NS. Group II:
n = 28; age 65 (range 50–79); sex 7 M (25%), 21 F (75%); BMI NS; Co NS | Group I: Two-level “gap” osteotomy (Mittelmeier) Group II: LCW HTO Fixation: gap osteotomy: non-locking plate; LCW: AO buttress plate | Partial weight-bearing for 6–12 weeks | – | – Definition of pre-op: pre-surgery | – | Unknown | 89% (in both groups). Time to RTW: 8–12 months | Mentioned, not adjusted for: age, pt motivation (“agricultural workers have to work until they are 80 years old”) |
Study: Lerat et al. [48], 1993, France [French] Design: ret cs; FU 4 years (range 4–11) Population: Pts with chronic ACL deficiency associated with medial OA and varus malalignment (n = 49); age 37 (range 25–58); sex 39 M (80%), 10 F (20%); BMI NS; Co NS | Valgising HTO + ACL reconstruction Fixation: plate 20, staples 31 | Removable splint for 4–6 weeks. Early mobilization with CPM. Weight bearing allowed after 2 months | Sports participation (pre-injury/pre-surgery, n(%)) |
n = 28 |
n = 28 | 48/63% RTS (%) | Unknown. Time to RTW: 5.1 months ± (range 3–18) | Mentioned, not adjusted for: surgeon’s advice |
Competition | 10/5 | 2 | 20/40 | |||||
Boxing | NS | 1 | NS | |||||
Tennis | NS | 1 | NS | |||||
Recreational sport | 15/14 | 10 | 67/71 | |||||
Definition of pre-op: pre-injury and pre-surgery | Time to RTS unknown | |||||||
Study: Minzlaff et al. [49], 2016, Germany Design: Cross-sectional; FU 6.9 years (range 2.5–9.8) Population: Pts with focal osteochondral defects of medial condyle and varus malalignment (n = 30); age 31 (range 19–39); sex NS; BMI 25 (range 21–32); Co NS; concomitant procedures: OATS 30 | LCW HTO n = 16; MOW HTO n = 14 Fixation: LCW: non-locking L-plate; MOW: TomoFix | CPM for 6–8 weeks, ROM not restricted. 6 weeks non-weight bearing, increased with 20 kg/week. PT for 6–8 weeks. RTS (contact sports) allowed after osteotomy healing | Tegner | 5 (2–7) | 5 (4–7) | 77% | Unknown | Adjusted for in analysis: age; defect size; number of previous surgeries. Mentioned, not adjusted for: donor-site morbidity |
Sports participation, n(%): | RTS (%) | |||||||
Overall | 30 | 23 | 77 | |||||
Oarsmanship | 1 | 1 | 100 | |||||
Horseback riding | 1 | 1 | 100 | |||||
Martial arts | 0 | 2 | >100 | |||||
Volleyball | 1 | 2 | >100 | |||||
Basketball | 1 | 0 | 0 | |||||
Handball | 0 | 1 | >100 | |||||
Soccer | 7 | 6 | 86 | |||||
Badminton | 1 | 1 | 100 | |||||
Table tennis | 1 | 2 | >100 | |||||
Tennis singles | 0 | 1 | >100 | |||||
Ice hockey | 1 | 0 | 0 | |||||
Snowboarding | 3 | 4 | >100 | |||||
C-C skiing | 3 | 4 | >100 | |||||
Downhill skiing | 5 | 8 | >100 | |||||
Gymnastics | 0 | 2 | >100 | |||||
Fitness training | 9 | 10 | >100 | |||||
Swimming | 10 | 11 | >100 | |||||
Mountain biking | 5 | 9 | >100 | |||||
Cycling | 15 | 17 | >100 | |||||
Climbing | 1 | 0 | 0 | |||||
Hiking | 3 | 8 | >100 | |||||
Inline skating | 3 | 2 | 67 | |||||
Jogging | 8 | 7 | 88 | |||||
Nordic walking | 2 | 3 | >100 | |||||
Definition of pre-op: lifetime and 1 year pre-surgery | Time to RTS: unknown | |||||||
Study: Nagel et al. [50], 1996, USA Design: ret; FU 8 years (range 2–14) Population: Pts with medial compartmental OA and varus malalignment (n = 34 [37 knees]). Group 1 (n = 12): preoperative Tegner ≤4. Group 2 (n = 22): preoperative Tegner ≥5. Age 49 (range 28–60); sex: 34 M (100%); BMI NS; Co NS | LCW HTO Fixation: above-the-knee cast 28, blade plate 8 | NS | Sports participation, n(%): | RTS (%) | Unknown. 26/34 regularly performed manual labor (painting, laying tile, paneling, carpentry, gardening, construction work). Time to RTW unknown | Adjusted for in analysis: pre-op sports level (most predictive for RTS). Mentioned, not adjusted for: sex; surgeon’s advice | ||
Overall | – | 25 | – | |||||
Tennis | 15 | 13 | 87 | |||||
Downhill + C-C skiing | 11 | 9 | 82 | |||||
Jogging | 14 | 10 | 71 | |||||
Cycling | 30 | 26 | 87 | |||||
Tegner (range) | ||||||||
Group I (n = 12) | 3.2 (2–4) | 2.8 (1–4) | ||||||
Group II (n = 22) | 6.5 (5–8) | 5.9 (2–8) | ||||||
Definition of pre-op: unknown (presumably pre-surgery) | Time to RTS: unknown | |||||||
Study: Niemeyer et al. [51], 2008, Germany Design: pro; FU 2 years Population: Pts with medial compartment OA and varus malalignment (n = 43); age 47.3 ± 10.3 (range NS); sex: 37 M (86%) 6 F (14%); BMI 27.2 ± 3.5; Co NS; concomitant procedures: n = 37 (ACL reconstruction 1; microfracturing 24; partial meniscectomy 17; ACI 7) | MOW HTO Fixation: TomoFix | Pts were mobilized on postoperative d1. Weight bearing limited to 15 kg for 6 weeks, after which, full weight bearing was allowed in all cases | Pre-disease sports activity level, n(%) | 68% regained predisease level of activity at 24 mo FU Time to RTS: unknown | Unknown | Adjusted for in analysis: smoking. Mentioned, not adjusted for: additional surgery; fixation type; pre-op sports level | ||
6 months | - | 13 (30%) | ||||||
12 months | - | 25 (58%) | ||||||
24 months | - | 29 (68%) | ||||||
Lysholm | 5 | 78 ± 20 (p < 0.01) | ||||||
IKDC (subjective) | 40 (NS) | 70 (NS) (p < 0.01) | ||||||
IKDC (objective), n(%) | ||||||||
Normal | 4 (9%) | 19 (44%) | ||||||
Nearly normal | 16 (37%) | 10 (23%) | ||||||
Abnormal | 15 (35%) | 12 (28%) | ||||||
Severely abnormal | 8 (18%) | 2 (5%) | ||||||
Definition of pre-op: pre-symptomatic | ||||||||
Study: Noyes et al. [33], 2000, USA Design: Pro cs; FU 4.5 years (range 2–12) Population: Pts with ACL deficiency and partial or complete lateral ligament deficiency and varus malalignment. Double varus: n = 23; age 30 (range 19–47); sex 21 M (91%), 2 F (9%); BMI NS. Triple varus: n = 18; age 28 (range 16–46); sex 11 M (61%), 7 F (39%); BMI NS. Co NS | LCW HTO Fixation: L-shaped internal plate | Long-leg brace for 8 weeks. Immediate ROM (0–90°). Toe-touch weight bearing for 3 weeks, gradually increased to full by wk 8–10. Quadriceps muscle isometric exercises, straight leg raises, patellar mobilization, and EMS | Sports participation, n(%): | >100%. Time to RTW unknown | Mentioned, not adjusted for: surgeon’s advice; non-homogenous population; staged surgery for complex cases | |||
Overall | 14 | 27 | >100% | |||||
Jumping, pivoting, cutting | 2 | 3 | >100% | |||||
Running, twisting, turning | 9 | 4 | 44% | |||||
Low impact (swimming, biking) | 3 | 24 | >100% | |||||
No sports | 27 | 10 | 37% | |||||
Employment, n(%) | Time to RTS unknown | RTW (%) | ||||||
Overall | 23 | 34 | >100 | |||||
Light | 11 | 20 | >100 | |||||
Moderate | 9 | 10 | >100 | |||||
Very heavy | 3 | 4 | >100 | |||||
Student/homemaker | 9 | 4 | – | |||||
Disabled (because of knee condition) | 9 | 3 | 33 | |||||
Definition of pre-op: pre-surgery | ||||||||
Study: Saier et al. [52], 2015, Germany Design: pro cs; FU 2 years Population: Pts aged <65 with medial compartment OA and varus malalignment (n = 64); age 45.5 (range 20–63); sex 46 M (74%), 18 F (26%); BMI 26.6 (range 19–35); Co NS | MOW HTO (biplanar) Fixation: TomoFix plate, Peek power plate | Immediate FROM. Partial weight bearing for 2 weeks, increased by 20 kg/wk until full weight bearing. RTS allowed after 3 months and contact sports after osseous consolidation | – | – Definition of pre-op: pre-surgery | – | Unknown | 93% (45/50). 90% without symptoms; 3% with impairment; 7% did not RTW due to knee symptoms. Time to RTW: 5.2 mo (range 1.5–24) | Adjusted for in analysis: psychological distress. Mentioned, not adjusted for: fixation type, surgeon’s advice |
Study: Salzmann et al. [53], 2009, Germany Design: Cross-sectional; FU 3 years (range 1.2–7) Population: Pts aged <65 with medial compartment OA and varus malalignment (n = 65); age 41.2 (range 19–65); sex 51 M (78%), 14 F (22%); BMI 21 (range 20–34); Co NS; concomitant procedures: n = 9 (partial meniscectomy 6, OATS 2, notchplasty 1) | MOW HTO (biplanar) Fixation: TomoFix plate | Partial weight bearing (15 kg) for 4 weeks. Weight-bearing gradually increased from week 4–6 and full weight bearing after 6–8 weeks | Sports activity (lifetime/pre-operative, n(%)) | 95% RTS (%) | Unknown | Adjusted for in analysis: age, ASA, BMI, concomitant procedures, correction angle, sex, KL score, satisfaction. (None of these factors were correlated with sports participation) | ||
Overall | 62/57 | 59 | 95/>100 | |||||
Cycling | 47/43 | 46 | 99/>100 | |||||
Downhill skiing | 35/18 | 18 | 51/100 | |||||
Swimming | 33/42 | 30 | 92/71 | |||||
Hiking | 29/17 | 20 | 68/>100 | |||||
Fitness | 27/13 | 17 | 63/>100 | |||||
Mountain biking | 19/13 | 14 | 70/>100 | |||||
C-C skiing | 19/7 | 5 | 28/71 | |||||
Tennis singles | 16/3 | 2 | 13/67 | |||||
Volleyball | 15/3 | 3 | 22/100 | |||||
Inline skating | 15/8 | 6 | 39/75 | |||||
Time to RTS: unknown | ||||||||
Tegner (range) | 4.9 (1–10) | 4.3 (2–9) (p < 0.05) | ||||||
Lysholm (range) | 42 (7–90) | 70 (22–95) (p < 0.01) | ||||||
Definition of pre-op: during lifetime and pre-surgery | ||||||||
Study: Saragaglia et al. [35], 2014, France Design: ret; FU 5.8 years (range 5–9) Population: Pts with medial compartment OA and varus malalignment (n = 83); age 50.4 (range 32–67); sex 56 M (68%), 27 F (32%); BMI 27.5 ± 4.7. Previous surgery: medial meniscectomy 23, ACL reconstruction 10; Co: 16% medical conditions that could hinder RTS | MOW HTO (n = 62) MOW HTO + LCW DFO (double osteotomy): n = 21 Fixation NS | NS | Sports participation, n(%)
| >100% RTS (%) | Unknown | Adjusted for in analysis: age, BMI, sex, type of osteotomy, motivation, pre-existent sports level. Mentioned, not adjusted for: Co, effect of double osteotomy, reasons for non-RTS | ||
Overall | 66 | 71 | >100 | |||||
Cycling | 28 | 26 | 93 | |||||
Power walking | 22 | 26 | >100 | |||||
Downhill skiing | 22 | 14 | 64 | |||||
Running | 20 | 17 | 85 | |||||
Hiking | 12 | 6 | 50 | |||||
Swimming | 9 | 13 | >100 | |||||
Tennis | 5 | 5 | 100 | |||||
Football | 4 | 1 | 25 | |||||
C-C skiing | 4 | 1 | 25 | |||||
Ski touring | 3 | 3 | 100 | |||||
Gymnastics | 3 | 2 | 67 | |||||
Gardening | 2 | 3 | >100 | |||||
Climbing | 2 | 2 | 100 | |||||
Windsurfing | 2 | 2 | 100 | |||||
Mountain bike | 2 | 1 | 50 | |||||
Bodybuilding | 1 | 2 | >100 | |||||
Golf | 1 | 1 | 100 | |||||
Handball | 1 | 1 | 100 | |||||
Bowls | 1 | 1 | 100 | |||||
Hunting | 1 | 1 | 100 | |||||
Squash | 1 | 1 | 100 | |||||
Diving | 1 | 1 | 100 | |||||
Volleyball | 1 | 0 | 0 | |||||
Rugby | 1 | 1 | 100 | |||||
Basketball | 1 | 0 | 0 | |||||
Lysholm (range) | 63 (30–100) | 91 (55–100) (p < 0.001) | 66 (80%) returned to same sporting level as before onset of OA. Time to RTS unknown | |||||
Tegner (range) | 4.5 (range NS) | 4.1 (range NS) (p = 0.07) | ||||||
UCLA (range) | 7.1 (range NS) | 6.6 (range NS) (p = 0.09) | ||||||
Definition of pre-op: pre-symptomatic | ||||||||
Study: Schröter et al. [54], 2013, Germany Design: ret; FU 6.4 ± 1.6 years (range NS) Population: Pts with medial compartment OA and varus malalignment who were employed at time of surgery (n = 32); age 47 ± 9; sex 22 M (69%), 10 F (31%); BMI 28.6 ± 4.7; Co NS | MOW HTO Fixation: LC-DCP plate | No brace or cast. 20-kg partial weight bearing for 6 weeks, full after 6–8 weeks. Active physiotherapy started after removal of drains | Lysholm (±SD) | 62.5 (±17.5) | 81.7 (±12.7) (p < 0.01) | Unknown | Unknown. Time to RTW: 87 days (14–450). Time to RTW for each REFA category: 0 = 42 days (14–150) 1 = 90 days (40–180) 2 = 120 days (28–450) 3 = 66 days (60–300) 4 = 120 days (120–120) 3 (9%) pts changed employment to occupation with lower workload | Adjusted for in analysis: workload. Mentioned, not adjusted for: fixation type, rehabilitation protocol, surgeon’s advice |
Tegner (range) | 3 (1–5) | 4 (1–8) (p = NS) | ||||||
REFA work (physical strain, n(%) | ||||||||
0 (without) | 7 (22) | 8 (25) | ||||||
1 (small) | 11 (34) | 11 (34) | ||||||
2 (moderate) | 8 (25) | 9 (28) | ||||||
3 (hard) | 5 (16) | 3 (9) | ||||||
4 (most heavy) | 1 (3) | 1 (3) | ||||||
Study: Waterman et al. [55], 2015, USA Design: ret; FU 4.0 years (range 2–8) Population: Active US duty service members undergoing HTO for coronal plane malalignment and/or intraarticular pathology (n = 181 [202 HTOs]); age 35.7 (range 15–55); sex 169 M (93%), 12 F (7%); BMI NS; Co NS. Concomitant procedures: n = 87 (meniscal 48, chondral 40, ligamentous 48) | MOW HTO Fixation: plate fixation (n = 171); external/ring fixation (n = 12); unspecified (n = 19) | NS | Combat deployment record, n(%) | 34 (19) | 15 (8.3) | Unknown | 72% returned to military duty, 43% without limitations. 8.3% successfully completed postoperative combat deployment. 41% had minor permanent activity limitations | Adjusted for in analysis: age, complications, concomitant procedures, sex, smoking. Mentioned, not adjusted for: selected (military) population, surgeon’s advice |
Definition of pre-op: pre-surgery | ||||||||
Study: Williams et al. [56], 2003, USA Design: ret; FU 3.8 years (range 2.0–8.8) Population: Pts with chronic ACL deficiency, medial compartment OA and varus malalignment (n = 25); age 35 (range 26–46); sex 18 M (72%) 7 F (28%); BMI NS; Co NS | LCW HTO (n = 12) LCW HTO + ACL reconstruction (n = 13) Fixation: two staples | Hinged knee brace. Non-weight bearing for minimum 4 weeks | Sports participation, n(%)
| RTS (%) | Unknown | Adjusted for in analysis: concomitant procedures (ACL | ||
Overall | 13 | 25 | >100 | |||||
Competitive sports | 2 | 4 | >100 | |||||
Recreational sports | 12 | 19 | >100 | |||||
Unable to participate in sports activities | 11 | 2 | – | |||||
Lysholm (range) | ||||||||
Group 1 | 46.8 (19–64) | 76.3 (57–100) (p < 0.05) | ||||||
Group 2 | 47.0 (14–73) | 80.9 (56–95) (p < 0.05) | ||||||
Tegner (range) | ||||||||
Group 1 | 3.8 (1–7) | 4.9 (3–7) (p < 0.02) | ||||||
Group 2 | 3.6 (1–7) | 4.7 (3–8) (p < 0.02) | ||||||
Definition of pre-op: immediately prior to surgery | ||||||||
Study: Yim et al. [57], 2013, South Korea Design: cross-sectional; FU 3.6 years (range 3–4) Population: Pts with medial compartment OA and varus malalignment (n = 58); age 58.3 (range 43–65); sex 7 M (12%), 51 F (88%); BMI NS; Co NS | MOW HTO Fixation: two Aescula wedge plates | ROM exercises, patellar mobilization, and straight-leg raises from postoperative d1. Partial weight bearing after 6 weeks, full weight bearing with a crutch after 8–12 weeks | Tegner | 3.1 ± 1.1 | 2.5 ± 1.2 (p = NS) | 78%. Time to RTS unknown | Unknown | Mentioned, not adjusted for: age, selected population (rural areas) |
Lysholm | 62.4 ± 9.5 | 89.6 ± 8.7 (p = NS) | ||||||
Participation in ≥1 low-impact activities, n(%): | ||||||||
0 activities | 8 | 19 | ||||||
≥1 activities | 50 Definition of pre-op: pre-surgery | 39 |
2.4 Data Extraction
2.5 Pooling Data
3 Results
3.1 Literature Search
3.2 Study Characteristics
3.2.1 Demographic Data
3.2.2 Surgical Technique
3.3 Methodological Quality
Study (n = 26) | Study participation | Study attrition | Prognostic factor | Outcome | Confounding factors | Analysis | Overall risk of biasa
|
---|---|---|---|---|---|---|---|
Ampollini et al. [42] | Moderate | Low | Low | Moderate | High | Moderate | Moderate |
Bode et al. [25] | Low | Low | Low | Low | High | Low | Moderate |
Bonnin et al. [43] | Moderate | High | Moderate | Low | High | Low | High |
Boss et al. [44] | Moderate | Low | Low | High | High | Low | High |
Boussaton et al. [41] | Moderate | Low | Moderate | High | High | Moderate | High |
Cotic et al. [45] | Low | Low | Low | Low | Moderate | Low | Low |
Dahl et al. [40] | Low | Low | Low | Low | Moderate | Low | Low |
De Carvalho et al. [38] | Low | Moderate | Low | Moderate | High | Low | Moderate |
Dejour et al. [46] | Moderate | High | Low | Low | High | High | High |
Faschingbauer et al. [47] | Low | Moderate | Low | Low | Moderate | Low | Low |
Gomoll et al. [36] | Low | Low | Low | Low | High | High | High |
Hoell et al. [34] | Moderate | Moderate | Low | Low | High | High | High |
Isolauri et al. [37] | High | High | Moderate | High | High | High | High |
Korovessis et al. [39] | Low | Moderate | Moderate | Moderate | High | Low | Moderate |
Lerat et al. [48] | High | High | Moderate | Moderate | High | Low | High |
Minzlaff et al. [49] | Low | Low | Low | Moderate | Low | Low | Low |
Nagel et al. [50] | High | High | Low | Low | Moderate | Moderate | High |
Niemeyer et al. [51] | Low | Low | Low | Low | High | Low | Moderate |
Noyes et al. [33] | Moderate | Low | Low | Moderate | High | Low | Moderate |
Saier et al. [52] | Low | Moderate | Low | Low | Low | Low | Low |
Salzmann et al. [53] | Moderate | Moderate | Low | Moderate | High | Moderate | Moderate |
Saragaglia et al. [35] | High | Moderate | Low | Moderate | Low | Low | Moderate |
Schröter et al. [54] | Low | Moderate | Low | Low | High | Low | Moderate |
Waterman et al. [55] | Low | Low | Moderate | Low | Low | Moderate | Low |
Williams et al. [56] | Moderate | Moderate | Low | Moderate | High | Moderate | Moderate |
Yim et al. [57] | Low | Low | Low | Moderate | Moderate | Low | Low |
3.4 Return to Sport
Preoperative reference for RTS | No. of pts participating in any sport preoperatively | No. of pts participating in any sport postoperatively | RTS (%) |
---|---|---|---|
Overall (16 studies) | 463 | 434 | 94 |
Pre-surgery status as reference for RTS (7 studies) | 150 | 167 | 111 |
Pre-symptomatic status as reference for RTS (9 studies) | 313 | 267 | 85 |
Low risk of bias studies (5 studies) | 181 | 149 | 82 |
Impact | Sports participation preoperatively (n = 10 studies) | Sports participation postoperatively (n = 11 studies) | ||||
---|---|---|---|---|---|---|
Sports (n) | Patients (n) | Average sports/patient, n (%) | Sports (n) | Patients (n) | Average sports/patient, n (%) | |
Low (e.g. cycling, swimming, golfing) | 413 | 453 | 0.91 (47) | 658 | 592 | 1.11 (58) |
Intermediate (e.g. hiking, downhill skiing) | 303 | 453 | 0.67 (35) | 369 | 592 | 0.62 (32) |
High (e.g. tennis, running, ball sports) | 159 | 453 | 0.35 (18) | 109 | 592 | 0.18 (10) |
Total | 875 | 453 | 1.93 | 1136 | 592 | 1.92 |
3.5 Return to Work
Study (n = 7) | Number of working patients | Time to RTW | ||||
---|---|---|---|---|---|---|
Preoperative (n) | Postoperative (n) | RTW (%) | Study (n = 6) | Patients (n) | Inability to work (weeks) | |
Dahl et al. [40] | 43 | 38 | 88 | Bode et al. [25] | 40 | 13.5 |
De Carvalho et al. [38] | 26 | 23 | 88 | Faschingbauer et al. [47] | 40 | 16.7 |
Faschingbauer et al. [47] | 43 | 40 | 93 | Hoella (ow) et al. [34] | 40 | 13.9 |
Korovessis et al. [39] | 63 | 54 | 86 | Hoella (cw) et al. [34] | 51 | 13.6 |
Noyes et al. [33] | 23 | 34 | 148 | Lerat et al. [48] | 49 | 20 |
Saier et al. [52] | 50 | 45 | 90 | Saier et al. [52] | 64 | 20.8 |
Waterman et al. [55] | 181 | 130 | 72 | Schröter et al. [54] | 32 | 12.4 |
Total | 429 | 364 | 85 | Total | 276 | 16.3 |