No significant differences in complication and graft failure rates by type of surgery or osteotomy level after slope-reducing osteotomy with ACL reconstruction: A systematic review and meta-analysis.

PURPOSE: To determine whether anterior cruciate ligament (ACL) graft failure and complication rates differ by type of surgery, osteotomy level, or planned surgical stages in patients undergoing anterior closing wedge high tibial osteotomy combined with ACL reconstruction.

METHODS: A systematic review and meta-analysis searched MEDLINE, Scopus, Web of Science, and the Epistemonikos up to September 2026 for studies reporting complications in adults undergoing anterior closing wedge high tibial osteotomy with anterior cruciate ligament reconstruction. Paired reviewers independently screened, extracted, and assessed quality. Random-effects meta-analyses estimated overall proportions and 95% confidence intervals (CIs). Subgroup analyses evaluated differences by type of surgery (primary vs. revision ACL reconstruction), osteotomy level (supratubercular, transtubercular or infratubercular), and number of planned surgical stages (single- or two-stage procedures).

RESULTS: Sixteen observational studies comprising 664 patients (673 knees) were included. The estimated graft failure proportion was 1.7% (95% CI: 0.3%-7.9%), with no significant differences by type of surgery (p = 0.091), osteotomy level (p = 0.770) or planned stages (p = 0.736). Frequent postoperative events included symptomatic hardware (7.8%) and complication-related reintervention (4.4%). Major complications were uncommon, including delayed union or non-union (0.4%), deep infections (0.2%), and vascular or thromboembolic events (0.1%). Complication-related reinterventions differed significantly by osteotomy level (p = 0.0016), being higher with multiple techniques compared to infratubercular and supratubercular approaches. Postoperative recurvatum differed significantly by type of surgery (p = 0.0037). The certainty of evidence was rated very low for all outcomes.

CONCLUSIONS: Anterior closing wedge high tibial osteotomy combined with ACL reconstruction showed a consistent, low-complication safety profile across type of surgery, osteotomy levels, and planned stages, though very low certainty of evidence indicates insufficient power to detect differences rather than demonstrated equivalence. These findings do not inform optimal treatment strategy or timing, and further prospective comparative studies are needed to define the incremental benefit of slope correction relative to isolated reconstruction.

LEVEL OF EVIDENCE: Level IV, systematic review and meta-analysis.