Comparison of computer-assisted navigated technology and conventional technology in high tibial osteotomy (HTO): a meta-analysis

Figures & data

Figure 1. Flow chart of the study selection procedure.

Table 1. The characteristics of included studies(a) in the meta-analysis.

First author(year)	Country	Type	Age (SD/range) [year]	Gender (F/M)	Keen (n)	Navigated system	Type of osteotomy
Neri 2019 [2]	Australia	Cohort study	Navigated group: 48.5 (±8)	Navigated group:61/215	Navigated group: 275	Stryker	Opening wedge
			Conventional group: 48.2 (±11.3)	Conventional group: 12/86	Conventional group: 98
Bae 2016 [13]	Seoul Korea	Cohort study	Navigated group: 57.7 (±6.7)	Navigated group: 55/5	Navigated group: 75	BrainlAB	Closing wedge
			Conventional group: 60.3 (±7.0)	Conventional group: 45/4	Conventional group: 75
Chang 2016 [30]	USA	Cohort study	Navigated group: 43.5 (±8.4)	Navigated group: 8/15	Navigated group: 33	OrthoPilot	Opening wedge
			Conventional group: 43.3 (±8.4)	Conventional group:18/56	Conventional group: 74
Schröter 2016 [35]	Germany	Randomized controlled trial	Navigated group: 45 (±8)	Navigated group: 9/47	Navigated group: 56	OrthoPilot	Opening wedge
			Conventional group: 47 (±8)	Conventional group: 21 /36	Conventional group: 57
Akamatsu 2016 [8]	Japan	Randomized controlled trial	Navigated group: 63.6 (±8.4)	Navigated group: 23/8	Navigated group: 31	Stryker	Opening wedge
			Conventional group: 66.3 (±8.4)	Conventional group: 23 /8	Conventional group: 31
Stanley 2016 [1]	Australia	Cohort study	Navigated group: 49.2 (range 30–64)	Navigated group:11/39	Navigated group: 52	BrainlAB	Opening wedge
			Conventional group: 47.6 (range 31–66)	Conventional group: 8/53	Conventional group: 65
Na 2015 [7]	Seoul Korea	Case-control study	Navigated group: 55.4 (±5.8)	Navigated group: 33/7	Navigated group: 40	OrthoPilot	Opening wedge
			Conventional group: 50.0 (±9.5)	Conventional group: 11 /9	Conventional group: 20
Ribeiro 2014 [4]	Brazil	Cohort study	Navigated Group: 46 (±6)	Navigated group:1/17	Navigated group:18	OrthoPilot	Opening wedge
			Conventional Group: 48 (±4)	Conventional group: 8/12	Conventional group: 20
Reising 2013 [33]	Germany	Case-control study	Navigated group: 43.6 (±11.4)	Navigated group: 8 /32	Navigated group: 40	OrthoPilot	Opening wedge
			Conventional group: 43.6 (±11.5)	Conventional group: 8 /32	Conventional group: 40
Iorio 2013 [31]	Italy	Randomized controlled trial	Navigated group: 56.5 (range 40–62)	Navigated group: 6/7	Navigated group:14	OrthoPilot	Opening wedge
			Conventional group: 54.8 (range 38–67)	Conventional group: 4/7	Conventional group:13
Akamatsu 2012 [29]	Japan	Case-control study	Navigated group: 62 (±9)	Navigated group: 21/5	Navigated group: 28	OrthoPilot	Opening wedge
			Conventional group: 57 (±9)	Conventional group: 11 /11	Conventional group: 31
Kim 2009 [32]	Seoul Korea	Case-control study	Navigated group: 54 (±4.8)	Navigated group: 4 /43	Navigated group: 47	Orthopilot	Opening wedge
			Conventional group: 53.5 (±5.8)	Conventional group: 5 /38	Conventional group: 43
Maurer 2006 [9]	Germany	Case-control study	NR	NR	Navigated group: 44	OrthoPilot	Opening wedge
					Conventional group: 23
Saragaglia 2005 [34]	France	Case-control study	Navigated group: 54 (range: 35–71)	NR	Navigated group: 28	Orthopilot	Opening wedge
			Conventional group: 55 (range: 27–70)		Conventional group: 28

NR: no report.

Table 2. The characteristics of included studies(b) in the meta-analysis.

First author(year)	Follow-up	Functional evaluation	Radiographic outcomes	Complications (Nav VS Con)	Operating time (SD)[Min]
Neri 2019 [2]	1.76 Years	IKDC, WOMAC scores, KOOS	Yes	38 Hardware removals, 1 wound hematoma, 2 revisions, 2 nonunions, and 2 meniscectomy/20 hardware removals, 1 wound hematoma, 1 meniscectomy, and 2 conversion to TKA	Navigated group: 97.1(±27.5)
					Conventional group: 84.3(±23.5)
Bae 2016 [13]	3 Months	NR	Yes	NR	NR
Chang 2016 [30]	NR	NR	Yes	10 Hardware removals, 3 infections, 2 revisions, 3 nonunions/9 hardware removals, 4 surgical site infections, 4 revisions, and 3 nonunions	Navigated group: 172(±34.4)
					Conventional group: 115.6(±31.9)
Schröter 2016 [35]	6 Weeks	NR	Yes	NR	Navigated group: 84(±17)
					Conventional group: 66(±17)
Akamatsu 2016 [8]	2 Years	AKSS, Lysholm score, ROM	Yes	0/0	Navigated group: 100(±11.2)
					Conventional group: 83.3(±.15.5)
Stanley 2016 [1]	1 Year	NR	No	0/0	NR
Na 2015 [7]	3 Months	NR	Yes	NR	Navigated group: 41.3 (±.5.6)
					Conventional group: 39.2(±.4.9)
Ribeiro 2014 [4]	1 Year	Lysholm score	Yes	NR	NR
Reising 2013 [33]	NR	NR	Yes	NR	Navigated group: 104(16.6)
					Conventional group: 88(16.3)
Iorio 2013 [31]	39 Months (range: 12–72)	AKSS, VAS, MCRSQ	Yes	0/a Broken screw was observed in two patients	Nav group was 23 min longer than the conventional
Akamatsu 2012 [29]	NR	AKSS, Lysholm score, ROM	Yes	0/1 Knee with delayed union	Navigated group: 112(±21)
					Conventional group: 96(±10)
Kim 2009 [32]	1 Year	HSS, Lysholm score	Yes	Two of delayed union, and one of varus collapse/2 delayed union	Navigated group: 78.8(±3.9)
					Conventional group: 77.8(±3.6)
Maurer 2006 [9]	NR	NR	Yes	NR	NR
Saragaglia 2005 [34]	75 Days	NR	Yes	NR	NR

Nav: navigated group; Con: conventional group.

Yes: Better tibial posterior slope/mechanical axis through navigated; No: no difference; NR: no report.

WOMAC: Western Ontario and McMaster Osteoarthritis Index; AKSS: American Knee Society Knee Score; ROM: range of motion; HSS: hospital for special surgery; IKDC: International Knee Documentation Committee; KOOS: Knee injury and Osteoarthritis Outcome Scores; VAS: Visual Analogue Scale; MCRSQ: Modified Cincinnati Rating System Questionnaire.

Table 3. Non-RCTs studies quality.

				Study quality		NOS Scale
Author（year）	Country	Type	Level of evidence	Downs and Black Score	Selection	Comparability	Expose	Outcome	Total score
Neri 2019 [2]	Australia	Cohort study	III	21	***	**	–	***	********
Bae 2016 [13]	Seoul Korea	Cohort study	III	17	***	**	–	*	*******
Chang 2016 [30]	USA	Cohort study	III	20	**	***	–	**	*******
Stanley 2016 [1]	Australia	Cohort study	III	18	***	**	–	**	*******
Na 2015 [7]	Seoul Korea	Case-control study	III	16	**	**	**	–	******
Ribeiro 2014 [4]	Brazil	Cohort study	III	20	***	**	–	**	*******
Reising 2013 [33]	Germany	Case-control study	III	17	**	***	**	–	*******
Akamatsu 2012 [29]	Japan	Case-control study	III	18	**	**	**	–	******
Kim 2009 [32]	Seoul Korea	Case-control study	III	17	**	**	**	–	******
Maurer 2006 [9]	Germany	Case-control study	III	16	**	***	*	–	******
Saragaglia 2005 [34]	France	Case-control study	III	16	**	***	**	–	*******

A total NOS score was 9* and if the NOS score was over 6*, it would be considered as higher quality research.

Table 4. RCTs studies quality.

Studies	Randomized adequately^a	Allocation concealed	Patient blinded	Care provider blinded	Outcome assessor blinded	Acceptable drop-out rate^b	ITT Analysis^c	Avoided selective reporting	Similar baseline	Similar or avoided cofactor	Patient compliance	Similar timing	Quality^d
Schröter 2016 [32]	Yes	Yes	Yes	Unclear	Yes	Yes	No	Yes	Yes	Unclear	Yes	Unclear	High
Akamatsu 2016 [8]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Yes	No	Yes	Yes	High
Iorio 2013 [28]	Yes	Unclear	Yes	Unclear	No	Yes	No	Yes	Yes	Unclear	Yes	Yes	High

^aOnly if the method of sequence made was explicitly introduced could get a ‘Yes’.

^bDrop-out rate <20% could get a ‘Yes’, otherwise ‘No’.

^cITT: intention-to-treat, only if all randomized participants were analyzed in the group they were allocated to could receive a ‘Yes’.

^d‘Yes’ items more than 7 means ‘high’; more than 4 but no more than 7 means ‘moderate’; no more than 4 means ‘low’.

Figure 2. Forest plot diagram showed the risk difference in outliers of aimed limb alignment between navigated group and conventional group.

Figure 3. Forest plot diagram showed the risk difference in outliers of aimed TPS between navigated group and conventional group.

Figure 4. Forest plot diagram showed the mean difference in Lysholm score between navigated group and conventional group.

Figure 5. Forest plot diagram showed the AKSS between navigated group and conventional group.

Figure 6. Forest plot diagram showed the mean difference in ROM between navigated group and conventional group.

Figure 7. Forest plot diagram showed the risk difference of total complications between navigated group and conventional group.

Figure 8. Forest plot diagram showed the risk difference of delayed union between navigated group and conventional group.

Figure 9. Forest plot diagram showed the risk difference of reoperation between navigated group and conventional group.

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