Anterior cruciate ligament reconstruction with anterior closing wedge osteotomy for failed high tibial osteotomy-A case report

Anterior Closing Wedge Osteotomy for Failed Anterior Cruciate Ligament Reconstruction: State of the Art

The sagittal anatomy of the proximal tibia has a bearing on the forces exerted on the cruciate ligaments. A high posterior tibial slope is now a well-known risk factor causing failure of anterior cruciate ligament (ACL) reconstructions. The posterior slope can be calculated on short or full-length radiographs, MRI scans, or three-dimensional CT scans. Reducing the slope surgically by a sagittal tibial osteotomy is biomechanically protective for the ACL graft. An anterior closing wedge osteotomy may be contemplated when the lateral tibial slope is greater than 12°, in the setting of ACL reconstruction failure(s). Careful surgical planning to calculate the correction, taking into account knee hyperextension and patella height, is critical to avoid complications. It can be done above, at, or below the tibial tuberosity level. A transtuberosity correction can be done with or without a tibial tubercle osteotomy. This complex surgery can be conducted safely by meticulous execution to protect the posterior hinge and neurovascular structures and achieving stable fixation with staples. The limited literature available justifies the usage of anterior closing wedge osteotomy in appropriately selected patients.

EXCESSIVE HYPERCORRECTION AFTER OPEN WEDGE HIGH TIBIAL OSTEOTOMY

Introduction Currently there is a tendency of increasing the proportion of knee joint organ-preserving surgery. High tibial osteotomy (HTO) was recommended as a method of knee joint varus deformity treating in cases with extraarticular deformity. The question of necessary angle correction remains controversial, which does not harm biomechanics of knee and adjacent joints. And the issue of preventing excessive hypercorrection as a complication of osteotomy. Methods The clinical case of the 59-year-old patient who underwent primary HTO and revision HTO is analyzed in this article. The patient had a varus deformity of a left lower limb with isolated medial knee osteoarthritis. The patient complained only at pain and range of motion limitation in the knee joint. According to arthroscopy and magnetic resonance imaging (MRI) data, there was cartilage damage classified as Outerbridge 4 stage of the medial compartment. There were no signs of lateral compartment cartilage damage and patellofemoral joint arthritis. The patient's body mass index (BMI) was 28kg / m2. Varus deformity of the knee joint 10˚. Results The patient underwent a medial high tibial open wedge osteotomy. During preoperative planning topograms of the lower limb with a weight bearing were used. A clinical result before the operation according to the scales was: Knee injury and Osteoarthritis Outcome Score (KOOS) 46 points, Visual Analogue Scale (VAS) 7 cm., American Orthopaedic Foot and Ankle Society (AOFAS) 92 points. After 6 months from initial surgery: knee joint VAS 1 cm., ankle joint VAS 5 cm., KOOS 88 points, AOFAS 63 points. During clinical examination and according to instrumental studies, excessive valgus hypercorrection of the 11,2˚ noted. Also, tibial plafond inclination (TPI) and talar inclination (TI) significantly increased. 1,5 years after the primary osteotomy, a revision closed wedge osteotomy was performed. Valgus deformity of the knee joint became 3˚, axis of the ankle joint changed to normal values. Clinical and functional results after 6 months after revision osteotomy: KOOS 92 points, AOFAS 99 points, pain in the knee and ankle joint on the VAS scale 1 cm. Conclusions The case showed: careful preoperative planning before the operation and using of additional methods for monitoring intraoperative correction were important. Excessive valgus hypercorrection promotes good regeneration of the medial compartment cartilage, however it overloads a lateral compartment and adversely affects the ankle joint and foot.

Current Concepts in Anterior Tibial Closing Wedge Osteotomies for Anterior Cruciate Ligament Deficient Knees

PURPOSE OF REVIEW

Anterior closing wedge osteotomies (ACWO) are utilized to better restore knee stability and in situ forces on anterior cruciate ligament (ACL) grafts during ACL revision reconstruction while reducing the risk of retearing and subsequent revision procedures. However, clinical outcomes following ACWO for patients undergoing ACL reconstruction remains largely limited. The purpose of this review was to provide a concise overview of the current literature on indication, techniques, and outcomes following ACWO in ACL-deficient patients undergoing primary or revision ACL reconstruction while discussing the authors' preferred technique to ACWO during a staged ACL revision reconstruction.

RECENT FINDINGS

Currently available clinical studies and case reports have demonstrated ACWO to improve knee stability and outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction with low complication rates. The ACWO provides an adjunct surgical option to decrease graft failure while improving knee stability and post-surgical outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction. Further investigations are warranted to validate currently reported outcomes following ACWO in higher-level clinical studies with longer-term follow-up.