Consistent indications, targets and techniques for double-level osteotomy of the knee: a systematic review

Purpose: To systematically review and critically appraise the literature on double-level osteotomy (DLO) of the knee, and determine the indications, contraindications, targets and outcomes.

Materials and methods: A systematic literature search was performed on PubMed, Embase®, and Cochrane for studies that reported on DLO by any technique or approach, including indications, contraindications, and targets for DLO, as well as patient-reported outcome measures (pROMS) and radiographic angles.

Results: Twelve eligible studies were found: 9 case series and 3 studies that compared DLO to high-tibial osteotomy (HTO). In all studies, DLO was performed by medial opening-wedge tibial osteotomy and lateral closing-wedge femoral osteotomy. Seven specified that DLO was performed if simple HTO would exceed thresholds of postoperative medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), and/or predicted wedge size. The targets were 88°-95° for MPTA, 84°-89° for LDFA, and 0°-4° for hip-knee-ankle (HKA) angle. The 3 comparative studies reported lower MPTA after DLO (89.6°-92.5°) than after HTO (91.5°-98.3°). All 3 reported similar postoperative HKA after DLO (0.2°-4.4°) as HTO (0.4°-4.8°); only 2 compared postoperative LDFA, which was lower after DLO (85.4° and 84.9°) than HTO (88.7° and 88.8°). Two comparative studies reported postoperative overall KOOS which was slightly lower after DLO (351-403) than HTO (368-410); only 1 study reported separate items of the KOOS.

Conclusion: There was relative consistency between studies on the indications, targets and techniques for DLO. Furthermore, while the comparative studies reported similar preoperative MPTA, LDFA and HKA, the postoperative MPTA and LDFA were lower after DLO than after HTO, though both treatments achieved equivalent postoperative HKA.

Level of evidence: IV, systematic review.