Changes in Balance Outcomes Following High Tibial Osteotomy in Patients With Knee Osteoarthritis: A Systematic Review

Knee osteoarthritis (KOA) is often accompanied by impaired postural balance, which may persist despite surgical correction. High tibial osteotomy (HTO) is a standard joint-preserving procedure for medial KOA, but its influence on postural balance is unclear. This systematic review aimed to synthesize evidence on balance changes following HTO.

A systematic search was conducted in PubMed, Scopus, Web of Science, ProQuest, Science Direct, and Google Scholar (1990-October 2025) using the PECO framework. Eligible studies were observational designs including adults with KOA undergoing HTO and reporting balance-related outcomes. Methodological quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools, with separate checklists applied for longitudinal pre-post studies and cross-sectional studies.

Nine observational studies met the inclusion criteria which included 572 participants. Balance outcomes included force-plate analyses of center of pressure (COP) during bipedal or single-leg stance, indices of weight distribution and steadiness, dynamic COP trajectory during gait, and functional tests such as the Timed Up and Go and Tinetti assessment. Short-term postoperative (within the first 3-6 months after HTO) findings were inconsistent, with some studies showing selective improvements and others no change. At mid- to long-term follow-up (≥ 12 months postoperatively), more consistent improvements were observed in weight distribution symmetry and functional performance. However, global steadiness often remained inferior to healthy reference group. Methodological quality assessment indicated that all longitudinal pre-post studies were of moderate quality, whereas the cross-sectional study was rated as high quality based on JBI criteria.

Balance outcomes tended to improve following HTO, particularly in load distribution and certain functional measures; however, global postural stability often remained inferior to that of healthy individuals. These findings suggest that alignment correction alone may be insufficient to fully restore balance. Therefore, structured rehabilitation and more rigorous, standardized future studies are warranted.