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Simultaneous and staged bilateral medial opening wedge high tibial osteotomy: a systematic review and meta-analysis
Dave Osinachukwu Duru1, Ebenezeer Mussie2, Ryan M Degen3
1School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom.
Background:
Medial opening wedge high tibial osteotomy (MOWHTO) is an established joint-preserving procedure to correct varus malalignment. In bilateral cases, MOWHTO may be performed simultaneously under one anaesthetic or staged across separate admissions. This systematic review and meta-analysis evaluated patient-reported (PROMs), radiographic, peri-operative, and complication outcomes following simultaneous and staged bilateral MOWHTO.
Methods:
A PRISMA-compliant systematic review was conducted. Embase, PubMed, and Ovid MEDLINE were searched from inception to March 25, 2026. Studies reporting outcomes after simultaneous or staged bilateral MOWHTO in adults were included. Data extraction and methodological quality assessment were performed independently by two reviewers. Random-effects meta-analysis was performed where appropriate, with remaining outcomes synthesised descriptively.
Results:
Fourteen studies comprising 534 bilateral MOWHTO patients were included; 270 underwent simultaneous and 264 underwent staged procedures. Both approaches produced substantial improvements in PROMs and radiographic alignment. Comparative studies demonstrated no statistically significant difference in post-operative KSS between simultaneous and staged cohorts. Meta-analysis showed no significant difference in post-operative medial proximal tibial angle (MD -0.85°, 95% CI -2.34 to 0.64; I2 = 0%; p = 0.26) or posterior tibial slope (MD -0.81°, 95% CI -2.24 to 0.62; I2 = 0%; p = 0.27). Simultaneous MOWHTO was associated with shorter cumulative hospital stay. Complication reporting was heterogeneous and no consistent difference was observed, except higher infection rates in staged cohorts.
Conclusions:
Simultaneous and staged bilateral MOWHTO both provide substantial improvements in PROMs and radiographic outcomes. Surgical timing influences peri-operative burden and recovery trajectory. Given the low-quality and heterogeneous evidence base, surgical strategy should be individualised according to patient comorbidity, rehabilitation capacity, and preference. Future prospective comparative studies with standardised reporting and longer follow-up are required.
Level Of Evidence:
IV, systematic review and meta-analysis of Level II to IV evidence.
