KSSTA - 2026-05-01 - Journal Article; Systematic Review
Hardware-related symptoms are the most common complication after anterior closing wedge osteotomy performed with ACL reconstruction: A systematic review.
Kunze KN, Moews LD, Alfonsi S, Nawabi DH, Ollivier M, Alaia MJ, LaPrade RF, Chahla J
Topics
Key Takeaway
In 505 patients undergoing combined ACWO with ACLR, the overall complication rate was 9.7%, with symptomatic hardware comprising 6.1% of cases and postoperative ACL graft rupture occurring in only 1.7%.
Summary Depth
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Summary
This systematic review quantified complication rates of anterior closing wedge osteotomy performed concurrently with ACLR across 12 retrospective case series. Hardware-related symptoms were the dominant complication at 6.1%, with an overall complication rate of 9.7% (range 0–82.8%). Severe complications including nonunion, hinge fracture, neurovascular injury, and loss of sagittal correction were not reported across the pooled cohort.
Key Limitation
The wide complication rate range (0–82.8%) across included studies reflects profound heterogeneity in fixation constructs, PTS correction magnitude, and complication reporting thresholds, limiting the precision of any pooled estimate.
Original Abstract
PURPOSE
To systematically review existing literature to define the rate and types of complications of anterior closing wedge osteotomy (ACWO) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR).
METHODS
A systematic query of PubMed, Embase and Scopus databases was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2025. Studies were included if they reported complications in patients undergoing ACWO with concurrent ACLR. Data on demographics, surgical technique, fixation method, graft type, posterior tibial slope (PTS) correction and complications were extracted. Data were described narratively and presented as frequencies with ranges in order to avoid potential bias and misleading conclusions from pooling heterogeneous data.
RESULTS
Twelve retrospective case series comprising 505 patients undergoing combined ACLR with ACWO were included. The overall complication rate was 9.7% (range: 0%-82.8%). The most common complication was symptomatic hardware (6.1%), accounting for nearly half of all reported complications. The overall rate of postoperative ACL graft rupture was 1.7%. Other reported complications included arthrofibrosis (0.4%), infection (0.2%) and malunion (0.2%). No reported cases of nonunion, hinge fracture, neurovascular injury or loss of sagittal plane correction were reported.
CONCLUSION
ACWO performed during ACLR demonstrates a clinically relevant complication rate, with hardware-related symptoms constituting the most frequent adverse event. Severe complications were rare. ACWO may reduce but does not eliminate the risk of ACL graft failure in patients with elevated PTS and appears to be a safe and effective option when PTS correction is indicated.
LEVEL OF EVIDENCE
Level IV.