Findings

The highest‐quality evidence comparing HTO and UKA for medial‐sided OA rests with three RCTs, all using CWHTO, and published many years ago.¹–³ There was no statistical significance in 10‐year survival for patients with a mean age of 67 years (77% UKA; 60% HTO).³ Both groups had similar mean knee scores, functional Knee Society Scores, and British Orthopaedic Association scores at one, five,² and seven, 10 years.³ Range of motion did not differ significantly between cohorts.¹,² In terms of muscle torque, maximal gait velocity, and duration of single support, UKA patients demonstrated superior results at six months postoperatively compared to HTO patients at 12 months.¹ However, while UKA patients showed significantly greater free walking speed, step frequency, and step length at three months postoperatively, these differences disappeared at one and five years.² Lastly, only one of three studies investigated intraoperative and postoperative complication rates, revealing higher complication rates in HTO (28.1%) versus UKA (7.1%), including deep vein thrombosis, superficial wound infection, pseudarthrosis, hardware failure, and fracture in the HTO cohort versus arthrofibrosis with UKA.³ In summary, comparable outcomes with regard to survivorship, patient‐reported outcomes, ROM, and gait were found, with possible increased complication rates in HTO over UKA.¹–³ From these studies alone, however, superiority cannot be established. Furthermore, with increasing prevalence of OWHTO versus CWHTO, RCTs comparing OWHTO and UKA are required.

A systematic review and meta‐analysis of pooled results was conducted on studies of all levels of evidence: nine retrospective, three prospective randomized, and two prospective non‐RCTs (total 1041 knees undergoing HTO and 5497 knees undergoing UKA). The meta‐analysis demonstrated superior ROM following HTO, but less pain, higher rates of self‐perceived outcome as excellent/good, and fewer perioperative complications after UKA. However, the procedural indications and patient characteristics vary among studies. Indeed, both procedures yield satisfactory outcomes, though it appears that valgus HTO may be more appropriate for younger active patients and UKA more appropriate for older patients.⁶

Resolution of clinical scenario

• HTO and UKA are reasonable options for this middle‐aged, active individual.
  
• Older, high‐quality trials show similar results between CWHTO and UKA.
  
• With the advent of OWHTO and improved technology, consideration may be given to recent, lower‐level studies.
  
• Pooled meta‐analyses showed HTO patients had better ROM, but UKA patients reported less pain, better patient scores, and fewer perioperative complications.
  
• As this patient is young, nonobese, and possesses full ROM, and a desire to return to activity, a joint preserving procedure may be more appropriate.