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Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of randomized controlled trials
Accepted Manuscript Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of randomized controlled trials Zhan Wang, Yihua Zeng, Wei She, Xiangli Luo, Liyang Cai PII:
S1743-9191(18)31693-5
DOI:
https://doi.org/10.1016/j.ijsu.2018.10.045
Reference:
IJSU 4783
To appear in:
International Journal of Surgery
Received Date: 6 September 2018 Revised Date:
27 October 2018
Accepted Date: 31 October 2018
Please cite this article as: Wang Z, Zeng Y, She W, Luo X, Cai L, Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of randomized controlled trials, International Journal of Surgery, https:// doi.org/10.1016/j.ijsu.2018.10.045. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of randomized controlled trials Zhan Wang1 Yihua Zeng2 Wei She1 Xiangli Luo1 Liyang Cai1
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1 Department of Orthopaedics, Gansu Provincial Hospital, 204 Donggangxi Road, 730000 Lanzhou, Gansu Province, China; 2 Department of Internal medicine，Gansu province hospital rehabilitation center，Lanzhou city, Chengguan Dingxi Road No. 53，730050 Lanzhou ,Gansu Province ,China
Donggangxi
Road,
730000
Lanzhou,
Gansu
Province,
China.
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[email protected]
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Corresponding Author: Liyang Cai, Department of Orthopaedics, Gansu Provincial Hospital, 204 E-mail
Address:
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Please state any conflicts of interest
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none
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Author contribution
1
ACCEPTED MANUSCRIPT Please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. Others, who have contributed in other ways should be listed as contributors. Zhan Wang and Yihua Zeng: data collections, data analysis and writing. Wei She and Xiangli Luo: data collections and data analysis.
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Liyang Cai and Zhan Wang: study design, data collections.
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Liyang Cai: data analysis and writing.
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Guarantor The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
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Liyang Cai
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Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial
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osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of
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randomized controlled trials Abstract:
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Background: High tibial osteotomy (HTO) is an effective surgical technique that can stop or inhibit
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progression of knee osteoarthritis (OA) and avoid or postpone the need for knee arthroplasty. This
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meta-analysis determined whether opening-wedge high tibial osteotomy (OWHTO) was superior to
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closing-wedge high tibial osteotomy (CWHTO) in treatment of unicompartmental OA.
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Methods: Databases (PubMed, Embase, Web of Science, Cochrane Library and Google) were
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searched from the time of their establishment to 1st August 2018 for randomized controlled trials
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(RCTs) comparing OWHTO and CWHTO in patients with unicompartmental OA. The Cochrane risk
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of bias tool was used to assess methodological quality. Statistical analysis was performed with Stata
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12.0.
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Results: Nine RCTs (599 participants) were included in this meta-analysis. The pooled results
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showed that there were no significant differences between OWHTO and CWHTO VAS knee pain
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scores, HSS knee scores, walking distances or hip-knee-ankle (HKA) angles (P>0.05). Furthermore,
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there were no significant differences between the two groups in complication and survival rates
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(p>0.05). Nevertheless, there was a significantly greater tibial slope angle in OWHTO patients (P＜
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0.00001).
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Conclusion: CWHTO reduced the inclination of the tibial plateau, whereas OWHTO increased the
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posterior tilt, and these factors should be considered in the specific need of an individual patient when
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choosing the type of osteotomy. Therefore, we are unable to conclude which method is superior.
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Keywords: High tibial osteotomy; opening-wedge high tibial osteotomy; closing-wedge high tibial
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osteotomy; meta-analysis
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Introduction
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Osteoarthritis (OA) of the knee is one of the most common joint disorders; it may lead to joint
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dysfunction, i.e., a reduction of joint motion and physical disability, as a result of tissue degeneration
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and destruction and loss of articular cartilage[1]. Various surgical techniques are used to treat pain and
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dysfunction in knee OA, including arthroscopic surgery, high tibial osteotomy (HTO), 1
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unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA)[2,3]. Among these,
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HTO is the method most frequently used in young and active patients with unicompartmental knee
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OA[4,5]. HTO is performed to stop or inhibit progression of knee OA and to avoid or postpone knee
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arthroplasty in patients with unicompartmental knee OA[6]. HTO for the treatment of knee OA gained acceptance in the 1960s after studies were conducted
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by Jackson and Waugh[7]. Since then, many HTO techniques have been evaluated[5]. Among them,
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opening-wedge high tibial osteotomy (OWHTO) and closing-wedge high tibial osteotomy (CWHTO),
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both of which involve stabilization with a locking plate, become two of the most frequently used
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techniques[8]. OWHTO is a relatively new technique and is less involved than CWHTO in terms of
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surgical technique; for example, only one tibial cut needs to be made in OWHTO, and the osteotomy
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of the fibula is not necessary[9].
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In recent years, with introduction of new rigid locked implants in combination with new
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bone-substituting biomaterials, OWHTO has become more popular than CWHTO, avoiding the
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comorbidities associated with fibular osteotomy[10].
Nevertheless, there are ongoing discussions regarding the choice of method for preoperative
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planning, operative technique and osteotomy site. Alterations in joint line angles, posterior tibial slope,
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patellar height (PH), correction accuracy, and OWHTO and CWHTO survivorship durations are
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among the controversial issues[11].
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To help resolve these uncertainties, we performed a meta-analysis to evaluate the differences in
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clinical outcomes in patients undergoing OWHTO and CWHTO and to explore whether OWHTO is
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superior to CWHTO.
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Materials and methods
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According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis
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(PRISMA) criteria, we created a prospective protocol including objectives, literature-search strategies,
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eligibility criteria, outcome measurements and methods for statistical analysis.
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The work has been reported in line with PRISMA (Preferred Reporting Items for Systematic
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Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic
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reviews) Guidelines.
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Search strategy 2
ACCEPTED MANUSCRIPT We searched for eligible studies for this meta-analysis in PubMed, Embase, Web of Science,
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Cochrane Library and Google databases. The title, abstract and MeSH search terms included (“Open”)
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and (“Closed” OR “Closing”) and (“Osteotomy” OR “Tibial”). Search strategies can be seen in
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Supplement File 1. Studies published in English before 1st August 2018 were considered. Related
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references in the identified studies were manually searched. After the initial electronic search, eligible
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studies were screened carefully for other eligible studies.
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Eligibility criteria
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Eligible studies met the following criteria: 1) Articles were published in English in peer-reviewed
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journals; 2) Patients were treated with CWHTO or OWHTO; and 3) Randomized controlled trials
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(RCTs) were used to compare radiographic and/or clinical outcomes after CWHTO and OWHTO. The
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exclusion criteria were as follows: 1) duplicate articles; 2) cohort studies, case reports, editorials,
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reviews, letters and animal studies; and 3) data that could not be extracted.
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Data extraction
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For each eligible study, two reviewers independently extracted the following data: 1) publication
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year and first author; 2) sample size, patient age and gender distribution; 3) follow-up period; 4)
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radiographic and clinical outcome; and 5) other data, if essential. Any disagreement regarding data
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was reviewed by a third reviewer. In the event of missing data, we attempted to contact the
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corresponding authors for details. The details of radiographic outcomes included posterior tibial slope
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angle and hip-knee-ankle (HKA) angle. Clinical outcomes included visual analogue scale (VAS) knee
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pain scores, Hospital for Special Surgery (HSS) knee scores, walking distances, complications and
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CWHTO and OWHTO survivorship durations.
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Quality assessment
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The methodological quality of the included studies was independently evaluated by two
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reviewers using the Cochrane Collaboration’s tool for assessing the risk of bias (ROB). The domains
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evaluated were selection bias (random sequence generation and allocation concealment), performance
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bias (blinding of participants and personnel to the conditions), detection bias (blinding of outcome
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assessments), attrition bias (incomplete outcome data), reporting bias (selective reporting) and other
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biases (other sources of bias). Any disagreements were resolved by discussion or were arbitrated by
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the corresponding author. 3
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Statistical analysis The meta-analysis was performed using Stata 12.0 (Stata Corp., College Station, TX). For
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dichotomous variables, the risk ratio (RR) and 95% confidence interval (CI) was derived for each
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outcome; for continuous variables, we calculated the weighted mean difference (WMD) and 95% CI.
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Heterogeneity was assessed using a chi-square test and I-square statistic. We performed the
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meta-analysis using a random-effects model. A sensitivity analysis was performed to identify the
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source of the heterogeneity. For all analyses, P < 0.05 was considered statistically significant.
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Subgroup analysis was performed according to the following classification: risk of bias (low or
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unclear/high), effect model (fixed-effect model or random-effect model) and follow-up duration (≤ 2
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years or > 2 years).
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Results
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Study selection
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A total of 355 records (PubMed=118, Embase=99, Web of Science=55, Cochrane Library=50,
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Google database=33) were searched via database and manual searches. After removing duplicates,
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326 records were screened. After a thorough screening of titles and abstracts, 317 records were
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excluded. Finally, nine studies[10-18], totalling 599 patients (OWHTO=294, CWHTO=305), met the
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eligibility criteria and were included in the meta-analysis (Figure 1).
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General characteristics of the included studies
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The characteristics of the included studies are presented in Table 1. The dataset consisted of 599
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participants, including 294 knees that underwent OWHTO and 305 that underwent CWHTO. The
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sample size, gender ratio, average age and types of fixation were also noted. In each study, the
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demographic characteristics of the two groups were similar. Follow-up duration ranged from 0.5 years
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to 7.9 years.
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Risk of bias
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An overview of the judgement regarding each risk of bias item in the included trials is shown in
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Figure 2 and Figure 3. Random sequence generation was mentioned in all the included studies.
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Seven studies described in detail adequate allocation concealment and two studies did not introduce
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adequate allocation concealment. Only four studies reported blinding of participants and personnel to
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the conditions. Two studies mentioned conditions on blinding of outcome assessors. Eight of the 4
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included studies provided complete baseline information and described the similarities between the
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comparison groups. The kappa value between reviewers was 0.721.
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Outcomes of the meta-analysis
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VAS knee pain Seven studies reported VAS knee pain scores at <5 years after surgery. There was moderate
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heterogeneity among the included studies (I2=31.0%). Therefore, a random-effects model was used
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for statistical analysis. The results showed that there was no significant difference between the
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OWHTO and CWHTO groups in the VAS knee pain at <5 years after surgery (WMD=-0.04, 95% CI:
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-0.43–0.35, P=0.831, Figure 4).
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There were no significant differences between OWHTO and CWHTO groups at >5 years after surgery (WMD=0.34; 95% CI: -1.52–2.20; P=0.723; Figure 5).
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HSS knee score
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Data for HSS knee scores were only available in three studies. There was no significant
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heterogeneity (P=0.748, I2=0%). The pooled results showed that there was no significant difference
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between the OWHTO and CWHTO groups (WMD=2.72; 95% CI: -1.01– 6.44; P=0.153; Figure 6).
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Walking distance
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Two studies[15, 16] reported walking distances. There was no difference between the two groups
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(WMD=0.70; 95% CI: -0.51–1.91; P=0.257; Figure 6) and there was no significant heterogeneity
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(p=1.00, I2=0%, Figure 7).
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HKA angle
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Seven studies evaluated HKA angles at <5 years after surgery. There was moderate heterogeneity
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between the trials (I2=51.9%; P=0.052). Therefore, a random effects model was used for statistical
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analysis. There was no significant difference between the OWHTO and CWHTO groups in the HKA
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angle (WMD=0.31; 95% CI: -0.19–0.80; p=0.227; Figure 8).
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Two studies evaluated HKA angles at >5 years after surgery. There was high heterogeneity
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between the trials (I2=73.8%; P=0.051). Therefore, a random effects model was used for statistical
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analysis. There was no significant difference between OWHTO and the CWHTO groups in the HKA
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angle at >5 years after surgery (WMD=0.57; 95% CI: -1.77–2.91; p=0.633; Figure 9).
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Tibial slope angle 5
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OWHTO from 3 studies were pooled. Moderate heterogeneity (P=0.109, I2=54.9%) between the
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studies was observed. Therefore, a random-effects model was used for statistical analysis. The pooled
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results showed that there was a significantly greater tibial slope angle in the OWHTO patients than in
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the CWHTO patients (WMD=4.04; 95% CI: 2.31–5.78; P=0.000; Figure 10).
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Complications
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Complications were documented in three studies. Significant heterogeneity (I2=78.9%, P=0.009)
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between the studies was observed. Therefore, a random-effects model was used for statistical analysis.
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The pooled results showed no significant differences between the two groups in complications
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(RR=2.40; 95% CI: 0.61–9.38; P=0.208; Figure 11).
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Survival rates
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CWHTO and OWHTO survivorship durations were reported in two studies. The pooled results
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showed no significant difference between the two groups in survival rates (WMD=1.08; 95% CI:
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0.88–1.38; P=0.52; Figure 12), and there was moderately significant heterogeneity (P=0.189,
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I2=42.1%).
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Subgroup analysis and publication bias
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Table 2 presents the results of the subgroup analyses. There was no significant difference
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between VAS knee pain in the OWHTO and CWHTO groups, which was consistent across all the
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subgroup analyses. For the meta-analysis of OWHTO and CWHTO on VAS knee pain, there was no
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evidence of publication bias in the funnel plot (Figure 13 A) or the formal statistical tests (Begg test,
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P=0.275, Figure 13 B; or the Egger test, P=0.337, Figure 13 C).
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Discussion
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This is the first meta-analysis of RCTs that compares clinical and radiographic results and
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survival rates associated with OWHTO and CWHTO for knee OA patients. This current meta-analysis
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found that there were no significant differences between OWHTO and CWHTO in VAS knee pain
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scores, HSS knee scores, walking distances and HKA angles. However, tibial slope angles were
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significantly greater in the OWHTO patients than in the CWHTO patients. In addition, there were no
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significant differences between the two groups in complications and survival rates. A major strength
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of this meta-analysis was that we only included RCTs with either OWHTO or CWHTO. Moreover, 6
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we performed subgroup analyses according to follow-up time. Finally, we performed sensitivity
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analysis to identify the robustness of our meta-analysis. Only one meta-analysis on the topic has been published previously [19], a meta-analysis
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comparing leg-length change between the opening and closing-wedge HTO of knee OA patients. That
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study found that CWHTO seemed to be a better treatment option than OWHTO. However, that
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meta-analysis contained some methodological shortcomings, including errors in the inclusion criteria
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(included RCTs and non-RCTs) and data extraction and high heterogeneity.
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In the present study, VAS knee pain was the main outcome. We found that CWHTO and
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OWHTO had similar VAS knee pain at both short- and long-term follow-up. Wu et al.[20] found that
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there was no significant difference regarding VAS knee pain between the opening-wedge and
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closing-wedge HTO groups.
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The current meta-analysis showed that there was no significant difference in the HKA angles.
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However, other studies suggest that this is controversial[21,22]. Radiographic results showed no
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significant difference in the HKA angles between patients undergoing OWHTO compared to CWHTO.
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However, we found that changes in the posterior tibial slope and PH were significantly different
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between patients undergoing OWHTO or CWHTO. According to previous studies, the use of
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OWHTO can lead to a greater tibial slope angle than CWHTO[23]. Nerhus et al. found a decreased
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slope of 2.5° following CWHTO and an increased slope of 1° following OWHTO [11]. They found
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that placing a Puddu plate as posteriorly as possible may decrease the slope in OWHTO patients. The
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unintentional changes in slope after both the HTO procedures can and should be reduced or avoided
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with careful preoperative planning and use of an appropriate operative technique[24].
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Slope changes may, however, intentionally be used to improve stability in patients with anterior
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cruciate ligament (ACL) injuries or posterior cruciate ligament (PCL) injuries[25]. A reduced slope
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may be beneficial in ACL-deficient knees[26], whereas an increased slope may be beneficial in knees
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with PCL ruptures[32]. We found a significantly lower PH, as measured by the IS index, in the
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OWHTO group. A significant decrease in PH after OWHTO has also been found by several other
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authors. A decrease in PH following OWHTO is believed to be caused by distalization of the tibial
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tuberosity and/or elevation of the tibiofemoral joint line[27] and patellar tendon shortening[28].
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patients where the coronal plane of the tibial plateau is inclined forward and with a downward tilt.
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The tibial tubercle should be kept in the proximal cut bone block in order to avoid further reduction in
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patellar height and influencing joint activity. CWHTO may reduce the inclination of the tibial plateau,
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whereas OWHTO may increase the posterior tilt, and these factors should be considered in the actual
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need of an individual patient in the choice of osteotomy
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Previous studies showed that OWHTO was associated with a higher complication rate and that
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CWHTO was associated with earlier conversions to TKA[14]. Generally, morbidity caused by
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harvesting cancellous bone at the iliac crest to perform bone grafting accounts for nearly half of early
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complications[10]. However, our pooled results showed no difference between OWHTO and
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CWHTO in the incidence of complications. Kim et al.[8] reported that OWHTO had a 6.2% higher
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survival rate 10 years after surgery than did CWHTO.
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There are several possible reasons for the superior survival rate of OWHTO at 10 years. First,
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OWHTO is thought to allow a more accurate correction than CWHTO because it allows fine-tuning
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of the desired correction in both the coronal and sagittal planes[17]. A higher degree of precision can
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theoretically result in better mechanical alignment and possibly superior survivorship[8]. Second, the
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dynamics of knee alignment may lead to the inferior results of CWHTO[29]. However, we found no
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significant differences between OWHTO and CWHTO. Data on survival rates were only available in
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two RCTs in our meta-analysis, and this limited small number of samples may have weakened our
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analysis. Further studies focusing on the following aspects are needed: first, surgical approaches were
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included and mixed in the current meta-analysis; therefore single surgical approaches should be
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performed to identify the clinical outcomes between CWHTO and OWHTO. Long-term follow-up is
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needed to clarify the clinical outcomes between CWHTO and OWHTO for knee OA.
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Nevertheless, this study has the following limitations: (1) The studies included a variety of
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fixation devices and wedge components, and fixation methods were not uniform; therefore, significant
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heterogeneity was unavoidable; (2) it included studies which generally did not evaluate complications
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and survival rates in detail; and (3) it included a limited number of studies, and the small number of
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samples weakened our analysis.
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Conclusion 8
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CWHTO reduced the inclination of the tibial plateau, whereas OWHTO increased the posterior
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tilt; these factors should be considered in the specific need of an individual patient in f the choice of
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HTO. Therefore, we are unable to conclude which method is superior. Further high quality RCTs with
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longer follow-up times should be conducted to draw a more definitive conclusion.
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Provenance and peer review
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Not commissioned, externally peer-reviewed
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Magyar G, Ahl T, Vibe P, Toksvig-Larsen S, Lindstrand A. Open-wedge osteotomy by hemicallotasis or the closed-wedge technique for osteoarthritis of the knee. A randomised
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study of 50 operations. J Bone Joint Surg Br. 1999; 81: 444-8.
299
19.
301 302 303 304 305
Closing-Wedge High Tibial Osteotomy: A Systematic Review and Meta-Analysis. J Knee Surg. 2018; [Epub ahead of print].
20.
Wu L, Lin J, Jin Z, Cai X, Gao W. Comparison of clinical and radiological outcomes
between opening-wedge and closing-wedge high tibial osteotomy: A comprehensive
meta-analysis. PLoS One. 2017; 12: e0171700.
21.
306
van Houten AH, Heesterbeek PJ, van Heerwaarden RJ, van Tienen TG, Wymenga AB.
Medial open wedge high tibial osteotomy: can delayed or nonunion be predicted? Clin
307 308
Lee OS, Ahn S, Lee YS. Comparison of the Leg-Length Change between Opening- and
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Orthop Relat Res. 2014; 472: 1217-23. 22.
Meidinger G, Imhoff AB, Paul J, Kirchhoff C, Sauerschnig M, Hinterwimmer S. May
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smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for
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non-union. Knee Surg Sports Traumatol Arthrosc. 2011; 19: 333-9.
10
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23.
El-Azab H, Glabgly P, Paul J, Imhoff AB, Hinterwimmer S. Patellar height and posterior
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tibial slope after open- and closed-wedge high tibial osteotomy: a radiological study on 100
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patients. Am J Sports Med. 2010; 38: 323-9. 24.
315 316
in open-wedge valgus high tibial osteotomy. Am J Sports Med. 2011; 39: 851-6. 25.
317 318
Hinterwimmer S, Beitzel K, Paul J, et al. Control of posterior tibial slope and patellar height Shelburne KB, Kim HJ, Sterett WI, Pandy MG. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res. 2011; 29: 223-31.
26.
Seo SS, Kim OG, Seo JH, Kim DH, Kim YG, Lee IS. Complications and Short-Term
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Outcomes of Medial Opening Wedge High Tibial Osteotomy Using a Locking Plate for
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Medial Osteoarthritis of the Knee. Knee Surg Relat Res. 2016; 28: 289-96.
321
27.
Chae DJ, Shetty GM, Lee DB, Choi HW, Han SB, Nha KW. Tibial slope and patellar height after opening wedge high tibia osteotomy using autologous tricortical iliac bone graft. Knee.
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2008; 15: 128-33.
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28.
325 326
Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986; 1: 307-10.
29.
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Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The Install Award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year followup study. Clin Orthop Relat Res. 1999;
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18-27.
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329 330 331 Figure legend
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Figure 1. Flowchart of the study search and inclusion criteria.
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Figure 2. The risk of bias of the included randomized controlled trials. +, no bias; –, bias; ?, bias
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unknown.
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Figure 3. The risk of bias graph.
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Figure 4. Forest plots of the included studies comparing the VAS knee pain at <5 years.
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Figure 5. Forest plots of the included studies comparing the VAS knee pain at >5 years.
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Figure 6. Forest plots of the included studies comparing the HSS knee score.
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Figure 7. Forest plots of the included studies comparing the walking distance.
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Figure 8. Forest plots of the included studies comparing the HKA angle at <5 years.
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Figure 9. Forest plots of the included studies comparing the HKA angle at >5 years.
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Figure 10. Forest plots of the included studies comparing the tibial slope angle.
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Figure 11. Forest plots of the included studies comparing the complication rate.
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Figure 12. Forest plots of the included studies comparing the survival rate.
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Figure 13. Funnel plot (A), Begg’s test (B) and Egger’s test (C) of the VAS knee pain between
347
CWHTO
348 349
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Country
Sample size
Gender (Male/Female)
Age (Years)
Fixation method
OWHTO
CWHTO
OWHTO
CWHTO
OWHTO
CWHTO
OWHTO
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Author
Follow-up
Outcomes
CWHTO
Netherlands
26
24
20/6
12/12
47.7
52.6
Puddu plate
Staples
1 year
1,2,3,4
Brouwer 2006
Netherlands
45
47
32/13
27/20
48.7
50.4
Puddu plate
Staples
1 year
2,5,8
Duivenvoorden 2014
Netherlands
36
45
24/12
27/18
49.9
49.5
Puddu plate
Staples
7.3 years
3.4.6.9
Egmond 2016
Netherlands
25
25
15/10
16/9
47.1
50.3
Locked plate
Locked plate
7.9 years
2,3,6,8
Gaasbeek 2010
Netherlands
25
25
14/11
16/9
47.0
Four-hole locked
Four-hole locked
1 year
6,7
plate
plate
TomoFix plates and
TomoFix plates and
2 years
1,5,8
screws
screws
Staple
Puddu titanium
0.5 year
2,3,6,9
Norway
23
35
19
35
NS
NS
NS
Magyar 1999
Sweden
33
35
10/8
Magyar 1999
Sweden
46
50
NS
NS 12/3 NS
NS
49.8 NS
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Netherlands
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45
47
plate
55
53
External fixation
Staples
1 year
1,4,7,8
55
55
External fixation
Staples
2 years
1,2,5,9
Table 1 General characteristics of the included studies. 1, VAS knee pain at <5 years; 2, VAS knee pain at >5 years; 3, HSS knee score; 4, walking distance; 5, HKA angle at
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<5 years; 6, HKA angle at >5 years; 7, tibial slope angle; 8, complication rate; 9, survival rate.
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WMD (95% CI)
P Value
I2 (%)
Low
-0.13 (-0.58, 0.33)
0.591
39.7
Unclear/high
0.20 (-0.56, 0.96)
0.607
16.9
Fixed-effects model
-0.12 (-0.41, 0.91)
0.445
31.0
Random-effects model
-0.04 (-0.43, 0.35)
0.831
31.0
0.096
≤ 2 years
-0.00 (-0.48, 0.47)
0.992
10.1
0.102
>2 years
-0.02 (-0.78, 0.75)
0.968
59.6
Puddu plate
0.28 (-0.32, 0.88)
0.360
0.0
Others
-0.18 (-0.69, 0.32)
0.478
Subgroup
Interaction, P
Risk of bias 0.106
Follow-up duration
42.4
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0.069
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ACCEPTED MANUSCRIPT 1.
A meta-analysis was conducted to compare opening-wedge high tibial osteotomy (OWHTO) with closing-wedge high tibial osteotomy (CWHTO) in treating unicompartmental osteoarthritis (OA) patients. Only randomized controlled trials were included.
3.
CWHTO reduced the inclination of the tibial plateau, whereas OWHTO increased the posterior
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tilt, and these factors should be considered in the actual need of an individual patient in the choice
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of osteotomy.
S1743-9191(18)31693-5
DOI:
https://doi.org/10.1016/j.ijsu.2018.10.045
Reference:
IJSU 4783
To appear in:
International Journal of Surgery
Received Date: 6 September 2018 Revised Date:
27 October 2018
Accepted Date: 31 October 2018
Please cite this article as: Wang Z, Zeng Y, She W, Luo X, Cai L, Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of randomized controlled trials, International Journal of Surgery, https:// doi.org/10.1016/j.ijsu.2018.10.045. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of randomized controlled trials Zhan Wang1 Yihua Zeng2 Wei She1 Xiangli Luo1 Liyang Cai1
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1 Department of Orthopaedics, Gansu Provincial Hospital, 204 Donggangxi Road, 730000 Lanzhou, Gansu Province, China; 2 Department of Internal medicine，Gansu province hospital rehabilitation center，Lanzhou city, Chengguan Dingxi Road No. 53，730050 Lanzhou ,Gansu Province ,China
Donggangxi
Road,
730000
Lanzhou,
Gansu
Province,
China.
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[email protected]
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Corresponding Author: Liyang Cai, Department of Orthopaedics, Gansu Provincial Hospital, 204 E-mail
Address:
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International Journal of Surgery Author Disclosure Form The following additional information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated.
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Please state any conflicts of interest
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none
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Please state any sources of funding for your research None
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Please state whether Ethical Approval was given, by whom and the relevant Judgement’s reference number
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None
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Research Registration Unique Identifying Number (UIN) Please enter the name of the registry and the unique identifying number of the study. You can register your research at http://www.researchregistry.com to obtain your UIN if you have not already registered your study. This is mandatory for human studies only.
reviewregistry242
Author contribution
1
ACCEPTED MANUSCRIPT Please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. Others, who have contributed in other ways should be listed as contributors. Zhan Wang and Yihua Zeng: data collections, data analysis and writing. Wei She and Xiangli Luo: data collections and data analysis.
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Liyang Cai and Zhan Wang: study design, data collections.
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Liyang Cai: data analysis and writing.
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Is opening-wedge high tibial osteotomy superior to closing-wedge high tibial
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osteotomy in treatment of unicompartmental osteoarthritis? A meta-analysis of
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randomized controlled trials Abstract:
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Background: High tibial osteotomy (HTO) is an effective surgical technique that can stop or inhibit
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progression of knee osteoarthritis (OA) and avoid or postpone the need for knee arthroplasty. This
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meta-analysis determined whether opening-wedge high tibial osteotomy (OWHTO) was superior to
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closing-wedge high tibial osteotomy (CWHTO) in treatment of unicompartmental OA.
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Methods: Databases (PubMed, Embase, Web of Science, Cochrane Library and Google) were
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searched from the time of their establishment to 1st August 2018 for randomized controlled trials
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(RCTs) comparing OWHTO and CWHTO in patients with unicompartmental OA. The Cochrane risk
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of bias tool was used to assess methodological quality. Statistical analysis was performed with Stata
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12.0.
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Results: Nine RCTs (599 participants) were included in this meta-analysis. The pooled results
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showed that there were no significant differences between OWHTO and CWHTO VAS knee pain
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scores, HSS knee scores, walking distances or hip-knee-ankle (HKA) angles (P>0.05). Furthermore,
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there were no significant differences between the two groups in complication and survival rates
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(p>0.05). Nevertheless, there was a significantly greater tibial slope angle in OWHTO patients (P＜
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0.00001).
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Conclusion: CWHTO reduced the inclination of the tibial plateau, whereas OWHTO increased the
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posterior tilt, and these factors should be considered in the specific need of an individual patient when
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choosing the type of osteotomy. Therefore, we are unable to conclude which method is superior.
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Keywords: High tibial osteotomy; opening-wedge high tibial osteotomy; closing-wedge high tibial
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osteotomy; meta-analysis
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Introduction
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Osteoarthritis (OA) of the knee is one of the most common joint disorders; it may lead to joint
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dysfunction, i.e., a reduction of joint motion and physical disability, as a result of tissue degeneration
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and destruction and loss of articular cartilage[1]. Various surgical techniques are used to treat pain and
29
dysfunction in knee OA, including arthroscopic surgery, high tibial osteotomy (HTO), 1
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unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA)[2,3]. Among these,
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HTO is the method most frequently used in young and active patients with unicompartmental knee
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OA[4,5]. HTO is performed to stop or inhibit progression of knee OA and to avoid or postpone knee
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arthroplasty in patients with unicompartmental knee OA[6]. HTO for the treatment of knee OA gained acceptance in the 1960s after studies were conducted
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by Jackson and Waugh[7]. Since then, many HTO techniques have been evaluated[5]. Among them,
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opening-wedge high tibial osteotomy (OWHTO) and closing-wedge high tibial osteotomy (CWHTO),
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both of which involve stabilization with a locking plate, become two of the most frequently used
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techniques[8]. OWHTO is a relatively new technique and is less involved than CWHTO in terms of
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surgical technique; for example, only one tibial cut needs to be made in OWHTO, and the osteotomy
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of the fibula is not necessary[9].
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In recent years, with introduction of new rigid locked implants in combination with new
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bone-substituting biomaterials, OWHTO has become more popular than CWHTO, avoiding the
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comorbidities associated with fibular osteotomy[10].
Nevertheless, there are ongoing discussions regarding the choice of method for preoperative
45
planning, operative technique and osteotomy site. Alterations in joint line angles, posterior tibial slope,
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patellar height (PH), correction accuracy, and OWHTO and CWHTO survivorship durations are
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among the controversial issues[11].
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To help resolve these uncertainties, we performed a meta-analysis to evaluate the differences in
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clinical outcomes in patients undergoing OWHTO and CWHTO and to explore whether OWHTO is
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superior to CWHTO.
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Materials and methods
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According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis
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(PRISMA) criteria, we created a prospective protocol including objectives, literature-search strategies,
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eligibility criteria, outcome measurements and methods for statistical analysis.
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The work has been reported in line with PRISMA (Preferred Reporting Items for Systematic
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Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic
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reviews) Guidelines.
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Search strategy 2
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Cochrane Library and Google databases. The title, abstract and MeSH search terms included (“Open”)
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and (“Closed” OR “Closing”) and (“Osteotomy” OR “Tibial”). Search strategies can be seen in
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Supplement File 1. Studies published in English before 1st August 2018 were considered. Related
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references in the identified studies were manually searched. After the initial electronic search, eligible
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studies were screened carefully for other eligible studies.
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Eligibility criteria
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Eligible studies met the following criteria: 1) Articles were published in English in peer-reviewed
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journals; 2) Patients were treated with CWHTO or OWHTO; and 3) Randomized controlled trials
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(RCTs) were used to compare radiographic and/or clinical outcomes after CWHTO and OWHTO. The
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exclusion criteria were as follows: 1) duplicate articles; 2) cohort studies, case reports, editorials,
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reviews, letters and animal studies; and 3) data that could not be extracted.
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Data extraction
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For each eligible study, two reviewers independently extracted the following data: 1) publication
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year and first author; 2) sample size, patient age and gender distribution; 3) follow-up period; 4)
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radiographic and clinical outcome; and 5) other data, if essential. Any disagreement regarding data
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was reviewed by a third reviewer. In the event of missing data, we attempted to contact the
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corresponding authors for details. The details of radiographic outcomes included posterior tibial slope
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angle and hip-knee-ankle (HKA) angle. Clinical outcomes included visual analogue scale (VAS) knee
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pain scores, Hospital for Special Surgery (HSS) knee scores, walking distances, complications and
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CWHTO and OWHTO survivorship durations.
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Quality assessment
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The methodological quality of the included studies was independently evaluated by two
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reviewers using the Cochrane Collaboration’s tool for assessing the risk of bias (ROB). The domains
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evaluated were selection bias (random sequence generation and allocation concealment), performance
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bias (blinding of participants and personnel to the conditions), detection bias (blinding of outcome
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assessments), attrition bias (incomplete outcome data), reporting bias (selective reporting) and other
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biases (other sources of bias). Any disagreements were resolved by discussion or were arbitrated by
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the corresponding author. 3
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Statistical analysis The meta-analysis was performed using Stata 12.0 (Stata Corp., College Station, TX). For
90
dichotomous variables, the risk ratio (RR) and 95% confidence interval (CI) was derived for each
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outcome; for continuous variables, we calculated the weighted mean difference (WMD) and 95% CI.
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Heterogeneity was assessed using a chi-square test and I-square statistic. We performed the
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meta-analysis using a random-effects model. A sensitivity analysis was performed to identify the
94
source of the heterogeneity. For all analyses, P < 0.05 was considered statistically significant.
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Subgroup analysis was performed according to the following classification: risk of bias (low or
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unclear/high), effect model (fixed-effect model or random-effect model) and follow-up duration (≤ 2
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years or > 2 years).
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Results
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Study selection
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A total of 355 records (PubMed=118, Embase=99, Web of Science=55, Cochrane Library=50,
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Google database=33) were searched via database and manual searches. After removing duplicates,
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326 records were screened. After a thorough screening of titles and abstracts, 317 records were
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excluded. Finally, nine studies[10-18], totalling 599 patients (OWHTO=294, CWHTO=305), met the
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eligibility criteria and were included in the meta-analysis (Figure 1).
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General characteristics of the included studies
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The characteristics of the included studies are presented in Table 1. The dataset consisted of 599
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participants, including 294 knees that underwent OWHTO and 305 that underwent CWHTO. The
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sample size, gender ratio, average age and types of fixation were also noted. In each study, the
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demographic characteristics of the two groups were similar. Follow-up duration ranged from 0.5 years
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to 7.9 years.
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Risk of bias
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An overview of the judgement regarding each risk of bias item in the included trials is shown in
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Figure 2 and Figure 3. Random sequence generation was mentioned in all the included studies.
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Seven studies described in detail adequate allocation concealment and two studies did not introduce
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adequate allocation concealment. Only four studies reported blinding of participants and personnel to
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the conditions. Two studies mentioned conditions on blinding of outcome assessors. Eight of the 4
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included studies provided complete baseline information and described the similarities between the
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comparison groups. The kappa value between reviewers was 0.721.
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Outcomes of the meta-analysis
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VAS knee pain Seven studies reported VAS knee pain scores at <5 years after surgery. There was moderate
122
heterogeneity among the included studies (I2=31.0%). Therefore, a random-effects model was used
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for statistical analysis. The results showed that there was no significant difference between the
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OWHTO and CWHTO groups in the VAS knee pain at <5 years after surgery (WMD=-0.04, 95% CI:
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-0.43–0.35, P=0.831, Figure 4).
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There were no significant differences between OWHTO and CWHTO groups at >5 years after surgery (WMD=0.34; 95% CI: -1.52–2.20; P=0.723; Figure 5).
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HSS knee score
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heterogeneity (P=0.748, I2=0%). The pooled results showed that there was no significant difference
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between the OWHTO and CWHTO groups (WMD=2.72; 95% CI: -1.01– 6.44; P=0.153; Figure 6).
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Walking distance
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(WMD=0.70; 95% CI: -0.51–1.91; P=0.257; Figure 6) and there was no significant heterogeneity
135
(p=1.00, I2=0%, Figure 7).
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HKA angle
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between the trials (I2=51.9%; P=0.052). Therefore, a random effects model was used for statistical
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analysis. There was no significant difference between the OWHTO and CWHTO groups in the HKA
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angle (WMD=0.31; 95% CI: -0.19–0.80; p=0.227; Figure 8).
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Two studies evaluated HKA angles at >5 years after surgery. There was high heterogeneity
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between the trials (I2=73.8%; P=0.051). Therefore, a random effects model was used for statistical
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analysis. There was no significant difference between OWHTO and the CWHTO groups in the HKA
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angle at >5 years after surgery (WMD=0.57; 95% CI: -1.77–2.91; p=0.633; Figure 9).
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Tibial slope angle 5
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OWHTO from 3 studies were pooled. Moderate heterogeneity (P=0.109, I2=54.9%) between the
148
studies was observed. Therefore, a random-effects model was used for statistical analysis. The pooled
149
results showed that there was a significantly greater tibial slope angle in the OWHTO patients than in
150
the CWHTO patients (WMD=4.04; 95% CI: 2.31–5.78; P=0.000; Figure 10).
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Complications
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Complications were documented in three studies. Significant heterogeneity (I2=78.9%, P=0.009)
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between the studies was observed. Therefore, a random-effects model was used for statistical analysis.
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The pooled results showed no significant differences between the two groups in complications
155
(RR=2.40; 95% CI: 0.61–9.38; P=0.208; Figure 11).
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Survival rates
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CWHTO and OWHTO survivorship durations were reported in two studies. The pooled results
158
showed no significant difference between the two groups in survival rates (WMD=1.08; 95% CI:
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0.88–1.38; P=0.52; Figure 12), and there was moderately significant heterogeneity (P=0.189,
160
I2=42.1%).
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Subgroup analysis and publication bias
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Table 2 presents the results of the subgroup analyses. There was no significant difference
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between VAS knee pain in the OWHTO and CWHTO groups, which was consistent across all the
164
subgroup analyses. For the meta-analysis of OWHTO and CWHTO on VAS knee pain, there was no
165
evidence of publication bias in the funnel plot (Figure 13 A) or the formal statistical tests (Begg test,
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P=0.275, Figure 13 B; or the Egger test, P=0.337, Figure 13 C).
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Discussion
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This is the first meta-analysis of RCTs that compares clinical and radiographic results and
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survival rates associated with OWHTO and CWHTO for knee OA patients. This current meta-analysis
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found that there were no significant differences between OWHTO and CWHTO in VAS knee pain
171
scores, HSS knee scores, walking distances and HKA angles. However, tibial slope angles were
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significantly greater in the OWHTO patients than in the CWHTO patients. In addition, there were no
173
significant differences between the two groups in complications and survival rates. A major strength
174
of this meta-analysis was that we only included RCTs with either OWHTO or CWHTO. Moreover, 6
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we performed subgroup analyses according to follow-up time. Finally, we performed sensitivity
176
analysis to identify the robustness of our meta-analysis. Only one meta-analysis on the topic has been published previously [19], a meta-analysis
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comparing leg-length change between the opening and closing-wedge HTO of knee OA patients. That
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study found that CWHTO seemed to be a better treatment option than OWHTO. However, that
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meta-analysis contained some methodological shortcomings, including errors in the inclusion criteria
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(included RCTs and non-RCTs) and data extraction and high heterogeneity.
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In the present study, VAS knee pain was the main outcome. We found that CWHTO and
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OWHTO had similar VAS knee pain at both short- and long-term follow-up. Wu et al.[20] found that
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there was no significant difference regarding VAS knee pain between the opening-wedge and
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closing-wedge HTO groups.
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The current meta-analysis showed that there was no significant difference in the HKA angles.
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However, other studies suggest that this is controversial[21,22]. Radiographic results showed no
188
significant difference in the HKA angles between patients undergoing OWHTO compared to CWHTO.
189
However, we found that changes in the posterior tibial slope and PH were significantly different
190
between patients undergoing OWHTO or CWHTO. According to previous studies, the use of
191
OWHTO can lead to a greater tibial slope angle than CWHTO[23]. Nerhus et al. found a decreased
192
slope of 2.5° following CWHTO and an increased slope of 1° following OWHTO [11]. They found
193
that placing a Puddu plate as posteriorly as possible may decrease the slope in OWHTO patients. The
194
unintentional changes in slope after both the HTO procedures can and should be reduced or avoided
195
with careful preoperative planning and use of an appropriate operative technique[24].
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Slope changes may, however, intentionally be used to improve stability in patients with anterior
197
cruciate ligament (ACL) injuries or posterior cruciate ligament (PCL) injuries[25]. A reduced slope
198
may be beneficial in ACL-deficient knees[26], whereas an increased slope may be beneficial in knees
199
with PCL ruptures[32]. We found a significantly lower PH, as measured by the IS index, in the
200
OWHTO group. A significant decrease in PH after OWHTO has also been found by several other
201
authors. A decrease in PH following OWHTO is believed to be caused by distalization of the tibial
202
tuberosity and/or elevation of the tibiofemoral joint line[27] and patellar tendon shortening[28].
7
ACCEPTED MANUSCRIPT Therefore, OWHTO should be avoided for preoperative patients with a low patella and in
204
patients where the coronal plane of the tibial plateau is inclined forward and with a downward tilt.
205
The tibial tubercle should be kept in the proximal cut bone block in order to avoid further reduction in
206
patellar height and influencing joint activity. CWHTO may reduce the inclination of the tibial plateau,
207
whereas OWHTO may increase the posterior tilt, and these factors should be considered in the actual
208
need of an individual patient in the choice of osteotomy
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Previous studies showed that OWHTO was associated with a higher complication rate and that
210
CWHTO was associated with earlier conversions to TKA[14]. Generally, morbidity caused by
211
harvesting cancellous bone at the iliac crest to perform bone grafting accounts for nearly half of early
212
complications[10]. However, our pooled results showed no difference between OWHTO and
213
CWHTO in the incidence of complications. Kim et al.[8] reported that OWHTO had a 6.2% higher
214
survival rate 10 years after surgery than did CWHTO.
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There are several possible reasons for the superior survival rate of OWHTO at 10 years. First,
216
OWHTO is thought to allow a more accurate correction than CWHTO because it allows fine-tuning
217
of the desired correction in both the coronal and sagittal planes[17]. A higher degree of precision can
218
theoretically result in better mechanical alignment and possibly superior survivorship[8]. Second, the
219
dynamics of knee alignment may lead to the inferior results of CWHTO[29]. However, we found no
220
significant differences between OWHTO and CWHTO. Data on survival rates were only available in
221
two RCTs in our meta-analysis, and this limited small number of samples may have weakened our
222
analysis. Further studies focusing on the following aspects are needed: first, surgical approaches were
223
included and mixed in the current meta-analysis; therefore single surgical approaches should be
224
performed to identify the clinical outcomes between CWHTO and OWHTO. Long-term follow-up is
225
needed to clarify the clinical outcomes between CWHTO and OWHTO for knee OA.
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Nevertheless, this study has the following limitations: (1) The studies included a variety of
227
fixation devices and wedge components, and fixation methods were not uniform; therefore, significant
228
heterogeneity was unavoidable; (2) it included studies which generally did not evaluate complications
229
and survival rates in detail; and (3) it included a limited number of studies, and the small number of
230
samples weakened our analysis.
231
Conclusion 8
ACCEPTED MANUSCRIPT 232
CWHTO reduced the inclination of the tibial plateau, whereas OWHTO increased the posterior
233
tilt; these factors should be considered in the specific need of an individual patient in f the choice of
234
HTO. Therefore, we are unable to conclude which method is superior. Further high quality RCTs with
235
longer follow-up times should be conducted to draw a more definitive conclusion.
237
Provenance and peer review
238
Not commissioned, externally peer-reviewed
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239 References
241
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240
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Gaasbeek RD, Nicolaas L, Rijnberg WJ, van Loon CJ, van Kampen A. Correction accuracy
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El-Azab H, Glabgly P, Paul J, Imhoff AB, Hinterwimmer S. Patellar height and posterior
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tibial slope after open- and closed-wedge high tibial osteotomy: a radiological study on 100
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in open-wedge valgus high tibial osteotomy. Am J Sports Med. 2011; 39: 851-6. 25.
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Hinterwimmer S, Beitzel K, Paul J, et al. Control of posterior tibial slope and patellar height Shelburne KB, Kim HJ, Sterett WI, Pandy MG. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res. 2011; 29: 223-31.
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Seo SS, Kim OG, Seo JH, Kim DH, Kim YG, Lee IS. Complications and Short-Term
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Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986; 1: 307-10.
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18-27.
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329 330 331 Figure legend
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Figure 1. Flowchart of the study search and inclusion criteria.
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Figure 2. The risk of bias of the included randomized controlled trials. +, no bias; –, bias; ?, bias
335
unknown.
336
Figure 3. The risk of bias graph.
337
Figure 4. Forest plots of the included studies comparing the VAS knee pain at <5 years.
338
Figure 5. Forest plots of the included studies comparing the VAS knee pain at >5 years.
339
Figure 6. Forest plots of the included studies comparing the HSS knee score.
340
Figure 7. Forest plots of the included studies comparing the walking distance.
341
Figure 8. Forest plots of the included studies comparing the HKA angle at <5 years.
342
Figure 9. Forest plots of the included studies comparing the HKA angle at >5 years.
343
Figure 10. Forest plots of the included studies comparing the tibial slope angle.
344
Figure 11. Forest plots of the included studies comparing the complication rate.
345
Figure 12. Forest plots of the included studies comparing the survival rate.
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Figure 13. Funnel plot (A), Begg’s test (B) and Egger’s test (C) of the VAS knee pain between
347
CWHTO
348 349
AC C
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12
ACCEPTED MANUSCRIPT
Country
Sample size
Gender (Male/Female)
Age (Years)
Fixation method
OWHTO
CWHTO
OWHTO
CWHTO
OWHTO
CWHTO
OWHTO
RI PT
Author
Follow-up
Outcomes
CWHTO
Netherlands
26
24
20/6
12/12
47.7
52.6
Puddu plate
Staples
1 year
1,2,3,4
Brouwer 2006
Netherlands
45
47
32/13
27/20
48.7
50.4
Puddu plate
Staples
1 year
2,5,8
Duivenvoorden 2014
Netherlands
36
45
24/12
27/18
49.9
49.5
Puddu plate
Staples
7.3 years
3.4.6.9
Egmond 2016
Netherlands
25
25
15/10
16/9
47.1
50.3
Locked plate
Locked plate
7.9 years
2,3,6,8
Gaasbeek 2010
Netherlands
25
25
14/11
16/9
47.0
Four-hole locked
Four-hole locked
1 year
6,7
plate
plate
TomoFix plates and
TomoFix plates and
2 years
1,5,8
screws
screws
Staple
Puddu titanium
0.5 year
2,3,6,9
Norway
23
35
19
35
NS
NS
NS
Magyar 1999
Sweden
33
35
10/8
Magyar 1999
Sweden
46
50
NS
NS 12/3 NS
NS
49.8 NS
M AN U
Nerhus 2017
Netherlands
TE D
Luites 2009
SC
Brouwer 2005
45
47
plate
55
53
External fixation
Staples
1 year
1,4,7,8
55
55
External fixation
Staples
2 years
1,2,5,9
Table 1 General characteristics of the included studies. 1, VAS knee pain at <5 years; 2, VAS knee pain at >5 years; 3, HSS knee score; 4, walking distance; 5, HKA angle at
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<5 years; 6, HKA angle at >5 years; 7, tibial slope angle; 8, complication rate; 9, survival rate.
ACCEPTED MANUSCRIPT Test of
WMD (95% CI)
P Value
I2 (%)
Low
-0.13 (-0.58, 0.33)
0.591
39.7
Unclear/high
0.20 (-0.56, 0.96)
0.607
16.9
Fixed-effects model
-0.12 (-0.41, 0.91)
0.445
31.0
Random-effects model
-0.04 (-0.43, 0.35)
0.831
31.0
0.096
≤ 2 years
-0.00 (-0.48, 0.47)
0.992
10.1
0.102
>2 years
-0.02 (-0.78, 0.75)
0.968
59.6
Puddu plate
0.28 (-0.32, 0.88)
0.360
0.0
Others
-0.18 (-0.69, 0.32)
0.478
Subgroup
Interaction, P
Risk of bias 0.106
Follow-up duration
42.4
AC C
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Table 2 Subgroup analysis for VAS knee pain.
SC
Fixation method
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Effect-model
0.069
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ACCEPTED MANUSCRIPT 1.
A meta-analysis was conducted to compare opening-wedge high tibial osteotomy (OWHTO) with closing-wedge high tibial osteotomy (CWHTO) in treating unicompartmental osteoarthritis (OA) patients. Only randomized controlled trials were included.
3.
CWHTO reduced the inclination of the tibial plateau, whereas OWHTO increased the posterior
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2.
tilt, and these factors should be considered in the actual need of an individual patient in the choice
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of osteotomy.