Bone Grafts and Bone Substitutes for Opening-Wedge Osteotomies of the Knee: A Systematic Review

Purpose: To establish the rate of use of various void fillers in the setting of opening-wedge osteotomy around the knee, the types of fixation used, and the rates of delayed union or nonunion related to these variables. In addition, this review addressed short-term to midterm outcomes and complication rates associated with such procedures. Methods: The electronic databases Medline, Embase, and PubMed were searched using the methodology for systematic review as recommended by the Cochrane Collaboration. The search terms used were as follows: knee, osteotomy, knee joint, bone grafting, opening osteotomy, opening wedge, tibial osteotomy, femoral osteotomy, and bone substitute. We screened 1,383 articles and applied exclusion criteria. Fifty-six articles were included. Results: We included 3,033 cases of osteotomy in 2,910 patients. The mean age of patients was 50 years, with a mean follow-up period of 42 months. Male patients comprised 52% of patients. The mean alignment change was 10.8 degrees, shifting the mechanical axis to 5.1 degrees valgus. Delayed union/nonunion rates were 2.6%, 4.6%, and 4.5% for autograft, allograft bone, and synthetic bone substitutes, respectively (P = .03). Delayed union/nonunion rates were significantly lower for autograft compared with allograft (P = .03) and for autograft and allograft compared with synthetic bone substitutes (P < .0001). Non-locking plates (n = 2,148) had a rate of delayed union/nonunion of 3.7% and a mean loss of correction over time of 0.5 degrees. Locking plates (n = 681) had a rate of delayed union/nonunion of 2.6% and a loss of correction of 2.3 degrees. All mean knee outcome scores improved, and an overall complication rate of 14% was found. Conclusions: Opening-wedge osteotomy had good short-term to midterm outcomes with acceptable complication rates. The lowest rates of delayed union/nonunion were in autograft bone-filled osteotomies. Plate type does not appear to affect osteotomy union or loss of correction.