Simultaneous high tibial osteotomy and ACL reconstruction for combined genu varum and symptomatic ACL tear

Satisfactory long-term outcomes for combined anterior cruciate ligament reconstruction and lateral closing wedge high tibial osteotomy

PURPOSE

A combined anterior cruciate ligament (ACL) reconstruction and high tibial osteotomy (HTO) is considered a valuable treatment in young patients affected by symptomatic medial osteoarthritis and ACL deficiency. However, only a few studies have investigated the outcomes of this procedure, especially in the long term. Therefore, the aim of this study is to report clinical and radiographic outcomes of ACL reconstruction and lateral closing wedge HTO at a mean of 14 years of follow-up.

METHODS

Patients were prospectively evaluated pre-operatively, after 6.5 ± 2.7 years and 14.3 ± 2.2 years. Patient-reported outcome measures (PROMs) were collected, knee laxity was assessed through KT-1000 arthrometer, and limb alignment and knee osteoarthritis were evaluated on long-cassette radiographs. Survivorship of the surgical procedure was calculated through the Kaplan-Meier method.

RESULTS

32 patients were initially enrolled and completed the mid-term evaluation (6.5 ± 2.7 years), and 23 patients (72%) were available for the final evaluation at 14.3 ± 2.2 years after surgery. Statistically significant improvement was found for all the clinical scores (VAS, WOMAC, Tegner, subjective IKDC, objective IKDC) between the pre-operative status and the mid-term follow-up (p < .001). VAS, subjective IKDC and objective IKDC showed no statistically significant differences (p > .05) between the mid-term and the final follow-up; a significant decrease of WOMAC (p < .05) and Tegner (p < .001) was found from mid-term to final follow-up. Significant progression of osteoarthritis was found for all the knee compartments. The survivorship was 95.7% at 5 years, 82.6% at 10 years, and 72.8% at 15 years.

CONCLUSIONS

Combined ACL reconstruction and lateral closing wedge HTO showed satisfactory clinical outcomes and survivorship at a mean of 14 years follow-up.

LEVEL OF EVIDENCE

IV.

Excellent short-term results of dome-shaped high tibial osteotomy combined with all-inside anterior cruciate ligament reconstruction

PURPOSE

This study aimed to evaluate short-term outcomes at least 2 years after dome-shaped high tibial osteotomy (HTO) combined with all-inside anterior cruciate ligament reconstruction (ACL) in patients with persistent ACL insufficiency accompanied by pain due to varus deformity.

METHODS

The study enrolled 19 knees of 18 patients. The mean age was 58.4 ± 13.4 years and the mean postoperative follow-up period was 31.4 ± 6.6 months (24-49 months). JOA(Japanese Orthopaedic Association)-OA(osteoarthritis) score, Lysholm score, radiographic outcomes such as femoro-tibia angle (FTA) in a standing position, side-to-side difference in KT-1000 measurements were evaluated at pre op. and post operative final follow up. And arthroscopic evaluation was evaluated at the time of the HTO plate-removal procedure.

RESULTS

Before surgery, the mean JOA-OA score was 65.0 ± 13.5, the mean Lysholm score was 47.2 ± 16.2, the mean femoro-tibia angle (FTA) in a standing position was 183.8 ± 3.4° (range;180-190°), and the mean side-to-side difference in KT-1000 measurements was 4.1 ± 1.3 mm. After surgery, the mean JOA-OA score, Lysholm score, and side-to-side difference in KT-1000 measurements improved to 93.1 ± 6.0 (P < 0.00001), 94.2 ± 5.9 (P < 0.00001), and -0.2 ± 0.8 mm (P < 0.00001), respectively. The mean FTA decreased to 168.0 ± 3.3 (P < 0.00001), and the mean posterior tibial slope angle decreased to 5.0 ± 3.6° from 6.9 ± 2.6° preoperatively (P = 0.024). Arthroscopic evaluation during the HTO plate-removal procedure of 17 knees were performed at a mean of 16 months after the surgery. The reconstructed ACL graft in 13 knees were successful, a cyclops lesion in one knee, and looseness of the graft in three knees.

CONCLUSIONS

Dome-shaped HTO allows for a relatively high degree of varus correction and decreases the steep posterior tibial slope that causes excessive load on the ACL. Therefore, its use in combination with ACL reconstruction seems to be effective.

Combined ACL reconstruction and opening wedge high tibial osteotomy at 10-year follow-up: excellent laxity control but uncertain return to high level sport

PURPOSE

The purpose of this study was to report the long-term outcomes of a continuous series of patients who underwent simultaneous anterior cruciate ligament (ACL) reconstruction and opening wedge high tibial osteotomy (HTO) for varus-related early medial tibio-femoral osteoarthritis. It was hypothesized that this combined surgery sustainably allowed return to sport with efficient clinical and radiological results.

METHODS

From 1995 to 2015, all combined ACL reconstruction (bone-patellar tendon-bone graft) and opening wedge HTO for anterior laxity and early medial arthritis were included. Clinical evaluation at final follow-up used Tegner activity score, Lysholm score, subjective and objective IKDC scores. Radiologic evaluation consisted in full-length, standing, hip-to-ankle X-rays, monopodal weight-bearing X-rays and skyline views. AP laxity assessment used Telos™ at 150 N load. Student's t test was performed for matched parametric data, Wilcoxon for nonparametric variables and Friedman test was used to compare small cohorts, with p < 0.05.

RESULTS

35 Patients (36 knees) were reviewed with a mean follow-up of 10 ± 5.2 years. The mean age at surgery was 39 ± 9. At final follow-up 28 patients (80%) returned to sport (IKDC ≥ B): 11 patients (31%) returned to sport at the same level and 6 (17%) to competitive sports. Mean subjective IKDC and Lysholm scores were 71.8 ± 14.9 and 82 ± 14.1, respectively. The mean decrease of the Tegner activity level from preinjury state to follow-up was 0.8 (p < 0.01). Mean side-to-side difference in anterior tibial translation was 5.1 ± 3.8 mm. Three patients were considered as failures. The mean preoperative mechanical axis was 4.2° ± 2.6° varus and 0.8° ± 2.7° valgus at follow-up. Osteoarthritis progression for medial, lateral, and femoro-patellar compartments was recorded for 12 (33%, p < 0.05), 6 (17%, p < 0.001), and 8 (22%, p < 0.05) knees, respectively. No femoro-tibial osteoarthritis progression was observed in 22 knees (61%).

CONCLUSIONS

Combined ACL reconstruction and opening wedge HTO allowed sustainable stabilization of the knee at 10-year follow-up. However, return to sport at the same level was possible just for one-third of patients, with femoro-tibial osteoarthritis progression in 39% of cases.

LEVEL OF EVIDENCE

III.

Fibular Collateral Ligament/ Posterolateral Corner Injury: When to Repair, Reconstruct, or Both

The posterolateral corner (PLC) of the knee was regarded as the "dark side" of the knee because of limited understanding of its anatomy and biomechanics and because of poor outcomes after injuries to PLC structures. These injuries rarely occur in isolation, with 28% reported as isolated PLC injuries. Nonoperative treatment of these injuries has led to persistent instability, development of early osteoarthritis, and poor outcomes. Several techniques for reconstruction of the PLC have been described, and all are reported to improve outcomes. Biomechanically validated anatomic reconstructions are preferred because they restore native knee kinematics and improve clinical outcomes without over-constraining the knee.

[Sports activities after osteotomies around the knee]

In the current literature, the rate of return to sports following high tibial osteotomy is high. Patients are largely able to carry out the type of exercise done before the onset of symptoms and are satisfied with the clinical outcome. In general, however, a differentiated view of the sporting ability should be made, and the different requirements of the sport should be considered. A classification according to functional and biomechanical movement analysis seems to advisable. In addition, the recommendations of the treating physician seem to have a high impact on the postoperative level of the sports activities of the patients. A realistic assessment (by both the patient and the treating physician) that considers the sport, its requirements and the level of performance is necessary.

Outcomes of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction in anterior cruciate ligament deficient knee with osteoarthritis

Background

We aimed to evaluate clinical and radiological results after simultaneous open-wedge high tibial osteotomy (HTO) and anterior cruciate ligament (ACL) reconstruction in patients with ACL deficiency combined with medial uni-compartmental osteoarthritis (OA) and varus deformity.

Methods

This retrospective study was performed using data collected from 2005 to 2011 on a total of 24 patients who were diagnosed with ACL injury and medial unicompartmental OA with varus deformity, and who subsequently underwent simultaneous open-wedge HTO and arthroscopic ACL reconstruction. The mean follow-up duration was 5.2 years. For clinical outcomes, we evaluated Lysholm score, Tegner activity score, range of motion, Lachmann test, and pivot-shift test, and for radiological outcomes, we evaluated the degree of varus deformity, progression of medial OA, tibial posterior slope, anterior instability, and postoperative complication.

Results

There were no limitations in range of motion found in any cases. Three patients showed progressive osteoarthritis on the medial compartment. The mechanical femorotibial angle was significantly corrected from varus 7.0 degrees to valgus 1.2 degrees, and the tibial posterior slope was not significantly changed. The Lysholm and Tegner activity scores were significantly improved after surgery (from 58 to 94 points on the Lysholm scale and from 4.0 to 5.3 points on the Tegner activity scale). Although the Lachman test and the pivot-shift test showed significant improvements after surgery, instability greater than Gr II was observed in three patients on the Lachman test and in four patients on the pivot-shift test. The side-to-side difference improved from 9.6 mm to 4.2 mm postoperatively as assessed using a Telos® arthrometer. There were no cases of nonunion or fixation loss.

Conclusions

Simultaneous open-wedge HTO and ACL reconstruction in patients with ACL injury with medial compartmental OA showed satisfactory functional outcomes and postoperative activity level scores. However, some patients showed residual instability and progression of OA.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2161-0) contains supplementary material, which is available to authorized users.

ACL deficiency and varus osteoarthritis: high tibial osteotomy alone or combined with ACL reconstruction?

INTRODUCTION

This study investigates the mid- to long-term clinical and radiological outcome in patients with symptomatic varus osteoarthritis (OA) and deficiency of the anterior cruciate ligament (ACL) and analyzes whether there are differences between isolated high tibial osteotomy (HTO) or combined single-stage HTO and ACL reconstruction (ACLR).

METHODS

26 patients who underwent HTO alone (group 1) and 26 patients who underwent single-stage HTO and ACLR (group 2) because of varus OA and ACL deficiency were examined at a mean of 5.8 years (SD 3.6 years) post-operatively. Assessment at follow-up (FU) was performed using a questionnaire including clinical scores (Lysholm, IKDC) and the KT-2000 arthrometer to examine anterior knee stability. Radiographic knee alignment and signs of OA according to the classification of Kellgren and Lawrence (KL) were assessed pre-operatively and at FU.

RESULTS

Eighty-one percent of all patients reported an improvement of pain and 79% an improvement of instability without significant group difference. Significant worse results were observed in group 1 for the Lysholm score (group 1: 69.4, SD 15.7; group 2: 78.3, SD 16.4; p = 0.020) and the IKDC score (group 1: 64.8, SD 13.0; group 2: 74.0, SD 15.6; p = 0.006). No group difference was found for the KT-2000 examination. A significant post-operative increase of radiographic OA could be seen in both groups without significant group difference (KL pre-operative: 2.3, SD 0.63; KL FU: 2.8, SD 0.74; p < 0.001). The radiographic leg alignment at FU showed a significant lower valgus alignment in group 1 (group 1: 0.4 degree, SD 3.3 degree; group 2: 2.1 degree, SD 2.1 degree; p = 0.039). The rate of post-operative complications was low with 4%, and no significant group differences were found.

CONCLUSIONS

This study shows that HTO alone can improve pain and even subjective knee stability. Additional ACLR was in the mid term not associated with a higher increase of OA or a higher rate of post-operative complications in our study collective.

Surgical Management and Treatment of the Anterior Cruciate Ligament/Posterolateral Corner Injured Knee

Posterolateral knee injuries occur more commonly than in the past. These injuries most commonly occur concurrent with cruciate ligament tears. The main stabilizers of the posterolateral knee are the fibular collateral ligament, the popliteus tendon, and the popliteofibular ligament. These static stabilizers function to prevent increased varus, external rotation, and coupled posterolateral rotation of the knee. The most important clinical tests to diagnose posterolateral knee injuries are the varus stress test, posterolateral drawer, and dial tests. Varus stress radiographs are key objective means to diagnose these injuries. Anatomic- based reconstructions have been validated to restore stability and improve outcomes.

Simultaneous anterior cruciate ligament reconstruction and dome-shaped high tibial osteotomy for severe medial compartment osteoarthritis of the knee

Background

The optimal surgical procedure to address both anterior cruciate ligament (ACL) deficiency and medial compartment osteoarthritis (OA) has been controversial.

Case report

A 49-year-old woman with a 30-year history of chronic anterior cruciate ligament (ACL) deficiency, medial compartment osteoarthritis, and varus deformity presented with medial knee pain and apprehension with walking and playing soccer. Her preoperative range of motion was from 0° of extension to 135° of flexion. The anterior drawer sign (1+), Lachman test (1+), and pivot shift test (glide) were positive before surgery, as measured by the International Knee Documentation Committee knee examination form. The patient underwent simultaneous arthroscopic ACL single-socket and single-bundle reconstruction using hamstring tendons, dome-shaped high tibial osteotomy using the TomoFix fixation device, and mosaicplasty to the medial condyle. The standing femorotibial angle changed from 185° preoperatively to 172° postoperatively. Range of motion exercises were started 1 week after surgery, and partial weight bearing was allowed 2 weeks after surgery. The patient returned to her baseline physical level 2 years after the operation. Range of motion was -10° of extension and 130° of flexion, and the anterior drawer sign, Lachman test, and pivot shift test were all negative at the final 3-year follow-up.

Conclusion

An ACL reconstruction combined with a dome-shaped high tibial osteotomy using a locking plate is one option for treating an aged athlete with ACL deficiency and severe medial compartment osteoarthritis, and can allow the athlete to return to sports activity.

Clinical Outcomes of High Tibial Osteotomy for Knee Instability: A Systematic Review

Background:

In recent years there has been an increasing interest in high tibial osteotomy (HTO) to treat patients with chronic knee instability due to posterolateral corner (PLC), posterior cruciate ligament (PCL), and anterior cruciate ligament (ACL) insufficiencies with concurrent malalignment in the coronal and/or sagittal plane.

Purpose:

To perform a systematic review of the use of HTO for the treatment of knee ligament instability with concurrent malalignment.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of the literature was conducted for the treatment of combined knee ligament instability and malalignment with HTO using the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE (1980 to present); the queries were performed in July 2015. Terms searched included the following: high or proximal tibial osteotomy, unstable, instability, laxity, subluxation, tibial slope, and malalignment, in the knee joint. Inclusion criteria were as follows: HTO to treat instability of the knee joint in the sagittal and/or coronal plane, minimum 2-year follow-up with reported outcomes measures, English language, and human studies. Animal, basic science, and cadaveric studies were excluded as well as editorials, reviews, expert opinions, surveys, special topics, letters to the editor, and correspondence.

Results:

The search resulted in 460 studies. After applying exclusion criteria and removing duplicates, 13 studies were considered. Of the studies reviewed, knee ligament pathologies, previous surgeries, and measurement of knee stability were heterogeneous. However, all studies reported an improvement in knee stability after HTO. Most studies reported improvement in outcome scores. However, other studies did not provide preoperative scores for comparison. Reported complication rates ranged from 0% to 47%.

Conclusion:

Although HTO has been highly advocated and used in treating patients with ligamentous knee instability, there remains a paucity of high-quality studies. Included studies report improvement of instability as well as relatively high patient satisfaction and rate of return to sports. The heterogeneity of the pathology treated, follow-up time, and outcome measures limit comparison between studies.

Combined Biplanar High Tibial Osteotomy, Anterior Cruciate Ligament Reconstruction, and Abrasion/Microfracture in Severe Medial Osteoarthritis of Unstable Varus Knees

PURPOSE

To determine survivorship and functional results of medial open-wedge high tibial osteotomy (HTO) combined with anterior cruciate ligament reconstruction (ACLR) and a chondral resurfacing (CR) procedure (abrasion/microfracture) in patients with Kellgren-Lawrence grade 3 and 4 osteoarthritis with full-thickness cartilage defects, anterior cruciate ligament (ACL) insufficiency, and varus malalignment.

METHODS

From October 2005 to March 2009, all combined HTO (fixation with angular stable internal fixator), ACLR, and CR procedures in knees with symptomatic medial osteoarthritis (Kellgren-Lawrence grade 3 and 4), ACL insufficiency, varus malalignment (>4°), and full-thickness large-area cartilage defects were prospectively surveyed with a minimum follow-up period of 5 years regarding survival (not requiring arthroplasty), functional outcome (subjective International Knee Documentation Committee [IKDC] score), and subjective satisfaction. Clinical evaluation (objective IKDC parameters and KT-1000 [MEDmetric, San Diego, CA] measurement), radiologic evaluation, and revision arthroscopy were performed between 1 and 2 years postoperatively.

RESULTS

Twenty-three knees (mean age, 47.0 ± 5.8 years) were included. The rate of follow-up was 100% at 6.0 ± 0.8 years (range, 5.2 to 7.5 years), with no arthroplasty until then. The mean subjective IKDC score improved from 47.7 ± 11.1 to 72.8 ± 15.0 at 1 year, 70.9 ± 16.0 at 3 years, and 73.1 ± 16.4 at 5 years (P < .001). Clinical examination and revision arthroscopy were performed in 22 cases (95.5%) at 1.3 ± 0.5 years (range, 1.0 to 2.0 years). Four ACL grafts (18.1%) were insufficient, and 2 grafts (9.1%) were stable but showed signs of degeneration. Good cartilage regeneration was seen in most cases, but no correlation with subjective IKDC score was apparent (P = .528).

CONCLUSIONS

HTO in combination with ACLR and a CR procedure is effective in the treatment of severe medial osteoarthritis with concomitant ACL insufficiency and varus malalignment. The effect of the CR, as well as the reason for the considerable rate of graft insufficiency, remains unclear.

Clinical outcome after UKA and HTO in ACL deficiency: a systematic review

PURPOSE

In the treatment of medial osteoarthritis secondary to anterior cruciate ligament (ACL) injury there is no consensus about optimum treatment, with both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) being viable options. The aim of this review was to compare the outcomes of these treatments, both with or without ACL reconstruction.

METHODS

EMBASE, MEDLINE and the Clinical Trials Registers were searched to identify relevant studies. Studies meeting pre-defined inclusion criteria were assessed independently by two researchers for methodological quality and data extracted.

RESULTS

Twenty-six studies involving 771 patients were identified for inclusion. No randomized controlled trials were identified. Seventeen studies reported outcomes following HTO and nine studies reported outcomes following UKA. HTO patients were significantly younger than those receiving UKA, and ACL reconstruction patients were younger than non-reconstructed patients. Treatment with HTO ACL reconstruction had the lowest revision rate (0.62/100 observed component years) but the highest rate of complications (4.61/100 observed component years). Too little data were available to test for differences in outcome between different surgical techniques or prosthesis designs.

CONCLUSIONS

Limited conclusions about the optimum treatment can be made due to the absence of controlled trials. In patients treated with HTO ACL reconstruction, the high complication rate likely outweighs its minimally superior survival. Outcomes following UKA ACL reconstruction are similar to outcomes for UKA in the ACL intact knee without any increase in complications. As such in patients meeting indications for UKA, UKA ACL reconstruction should be performed with further work required to identify the optimum treatment in other patient groups.

LEVEL OF EVIDENCE

IV.

The role of high tibial osteotomy in the treatment of knee laxity: a comprehensive review

PURPOSE

The purpose of this study is to review the indications for and outcomes of high tibial osteotomy in the treatment of patients with chronic knee laxity.

METHODS

A comprehensive literature review was performed to identify surgical indications and results of high tibial osteotomy for the treatment of chronic knee laxity.

RESULTS

Four distinct situations were identified in which a high tibial osteotomy may be advantageous: (1) anterior laxity with varus osteoarthritis, (2) chronic anterior laxity in the setting of varus with lateral ligamentous laxity, (3) chronic anterior laxity in the setting of a high tibial slope, and (4) chronic posterior laxity or posterolateral corner injury. A total of 24 studies were included in this report, including reports of the treatment of 410 knees as well as several review articles. The most frequently reported indication for that addition of HTO was anterior laxity in the setting of varus OA, which was noted to have good results, minimizing anterior knee laxity and allowing return to sports, while reducing the progression of osteoarthritis. More advanced cases in which lateral structures have also become stretched and incompetent are an excellent indication for HTO, with the need for subsequent lateral procedures dependent on the degree of varus laxity and especially hyperextension that is present. Excessive tibial slope has been identified as a cause of ACL reconstruction failure, and some authors have recommended addressing very high slope in revision cases. In knees with chronic posterior or posterolateral instability, correction of alignment first is generally recommended, with subsequent ligamentous procedures performed when instability persists.

CONCLUSIONS

Knees with chronic instability pose a difficult treatment challenge. In all cases, the contribution of coronal plane alignment to varus-valgus knee stability must be carefully considered and addressed prior to ligament surgery. Sagittal plane alignment is also key and must not be overlooked. Such considerations drive the indication for osteotomy as well as the type of osteotomy that is chosen. Level of evidence IV.

Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in young patients with anterior cruciate ligament-deficient knees: a systematic review

PURPOSE

High tibial osteotomy (HTO) has been a well-established procedure addressing tibiofemoral osteoarthritis in young patients. However, for physically active patients with concomitant anterior cruciate ligament (ACL) injury, simultaneous HTO and ACL reconstruction is considered a salvage procedure. Controversy exists regarding the subjective and objective evaluations and the prevalence of complications.

METHODS

A search in the Medline database and of major orthopaedic journals was performed. Articles were included if they met the specific inclusion and exclusion criteria. Anterior knee laxity, osteoarthritis, subjective outcomes, sagittal and coronal alignment, and complications were analyzed.

RESULTS

A total of 721 articles were retrieved from the search, and 11 eligible studies (218 knees) were included for evaluation. Postoperatively, the mean side-to-side difference measured by KT-1000 (MEDmetric, San Diego, CA) was 2.4 mm, and 85.7% of patients gained grade A or B stability according to International Knee Documentation Committee evaluation. Medial compartment osteoarthritis showed a tendency of alleviation. Regardless of the scoring system, all subjective evaluations showed improvement and most of the participants returned to recreational sports. All cases of varus malalignment were corrected, with a mean value of 7.13°. The most prevalent complication was deep venous thrombosis (7.7%).

CONCLUSIONS

Simultaneous HTO and ACL reconstruction was a salvage procedure for physically active young patients because it provided satisfactory restoration of anterior stability, alleviation of medial compartment osteoarthritis, improvement of subjective evaluations, and a predictable return to recreational sports.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Anterior Cruciate Ligament Reconstruction and Osteoarthritis: Evidence from Long-Term Follow-Up and Potential Solutions

OBJECTIVE

The goals of this study are to address several questions, the answers to which are key to the understanding and eventually to the prevention of this frequent source of morbidity. These questions include the following: (1) What is the natural history of anterior cruciate ligament (ACL) deficiency? (2) How important is the status of the meniscus at the time of reconstruction? (3) Does ACL reconstruction prevent the development of osteoarthritis in the long term? (4) Can we predict which patients will develop osteoarthritis? (5) What can be done?

DESIGN

This study addresses the key questions above through the long-term follow-up of a cohort of patients treated with ACL reconstruction by Professor Henri Dejour in Lyon, France, supplemented with a review of the relevant literature.

RESULTS

The prevalence of osteoarthritis in ACL-deficient knees is about 40% after 15 years and close to 90% after 25 to 35 years. It remains unclear whether reconstruction of the ACL significantly reduces this risk. The status of the meniscus at the time of ACL reconstruction is a strong predictor of the risk of osteoarthritis: Patients who undergo total meniscectomy are at 2- to 10-fold increased risk of developing osteoarthritis relative to those with intact menisci. Patients showing early evidence of arthritis at short- to medium-term follow-up are at high risk for progression over subsequent years. Numerous emerging techniques may provide tools to more effectively prevent and treat osteoarthritis following ACL injury in the future.

CONCLUSION

Osteoarthritis following ACL injury continues to be a major problem requiring further research.

Effect of tibial slope on the stability of the anterior cruciate ligament-deficient knee

PURPOSE

We aimed to quantify the effect of changes in tibial slope on the magnitude of anterior tibial translation (ATT) in the anterior cruciate ligament (ACL)-deficient knee during the Lachman and mechanized pivot shift tests. We hypothesized that increased posterior tibial slope would increase the amount of ATT of an ACL-deficient knee, while leveling the slope of the tibial plateau would decrease the amount of ATT.

METHODS

Lachman and mechanized pivot shift tests were performed on hip-to-toe cadaveric specimens, and ATT of the lateral and the medial compartments was measured using navigation (n = 11). The ACL was then sectioned. Stability testing was repeated, and ATT was recorded. A proximal tibial osteotomy in the sagittal plane was then performed achieving either +5 or -5° of tibial slope variation after which stability testing was repeated (n = 10).

RESULTS

Sectioning the ACL resulted in a significant increase in ATT in both the Lachman and mechanized pivot shift tests (P < 0.05). Increasing or decreasing the slope of the tibial plateau had no effect on ATT during the Lachman test (n.s.). During the mechanized pivot shift tests, a 5° increase in posterior slope resulted in a significant increase in ATT compared to the native knee (P < 0.05), while a 5° decrease in slope reduced ATT to a level similar to that of the intact knee.

CONCLUSIONS

Tibial slope changes did not affect the magnitude of translation during a Lachman test. However, large changes in tibial slope variation affected the magnitude of the pivot shift.

Lower limb alignment in anterior cruciate ligament-deficient versus -intact knees

PURPOSE

To compare anatomic lower limb features of anterior cruciate ligament (ACL)-deficient versus -intact knees in Chinese subjects.

METHODS

Anatomic lower limb features (mechanical axis, tibiofemoral angle, posterior tibial slope, notch width index, and hip neck-shaft angle) of 25 men and 3 women aged 18 to 39 (mean, 26) years with ACL-deficient knees, and 16 men and 4 women aged 24 to 31 (mean, 28) years with ACL-intact knees were compared using radiography.

RESULTS

The notch width index (0.26 vs. 0.29, p=0.02) was significantly smaller in ACL-deficient than ACL-intact knees.

CONCLUSION

Small notch width was associated with a thin ACL and can be regarded as an anatomic intrinsic risk factor for ACL injuries.

Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-wedge high tibial osteotomy: a report of eight cases

Eight patients, aged 37-50 years, with chronic anterior cruciate ligament (ACL) deficiency, medial compartment osteoarthritis and varus deformity underwent simultaneous arthroscopic ACL reconstruction and open-wedge high tibial osteotomy controlled by a computer navigation system. Despite preoperative planning, the surgeon may need to choose a different osteotomy site during the procedure, invalidating the previous plans. The intraoperative wire control for osteotomies is not precise. The navigation system can help obtain precise alignment during high tibial osteotomy. The average preoperative mechanical axis was 7.5 of varum (sd±1.17°), the average postoperative axis was 1.2° of valgus (sd±1.04°) (p<0.01), and the average correction of the mechanical axis was 8.7° (sd±0.76°). The site of the osteotomy was 3.9 cm (3.5-4.8 cm, sd±0.35 mm) from the articular line, with an inclination of 27.9° (24-35, sd±4.8). The simultaneous use of these procedures allowed proper correction of the knee axis during the surgery. The surgery can be performed concomitantly with ACL reconstruction.

Is correctional osteotomy crucial in primary varus knees undergoing anterior cruciate ligament reconstruction?

BACKGROUND

Valgus high tibial osteotomy (HTO) has been recommended for ligament stability and enhanced function after anterior cruciate ligament (ACL) reconstruction in varus-angulated knees. However, it is not clear whether HTO should be performed in patients undergoing ACL reconstruction who have primary varus knees without medial compartment arthrosis.

QUESTIONS/PURPOSES

We therefore asked whether stability and function differed in patients having ACL reconstruction with differing degrees of preoperative alignment.

PATIENTS AND METHODS

We retrospectively reviewed 201 patients who had primary, single-bundle ACL reconstructions with primary varus knees based on the preoperative mechanical axis deviation (MAD) on preoperative standing hip-knee-ankle radiographs. Patients were categorized into four groups according to the MAD: Group 1: 0 mm to 4 mm, Group 2: 5 mm to 9 mm, Group 3: 10 mm to 14 mm, and Group 4: greater than 15 mm. A total of 201 patients, 67 in Group 1, 53 in Group 2, 38 in Group 3, and 43 in Group 4, were assessed. Ligament stability was determined with the Lachman test, pivot shift test, and KT 2000™ arthrometer. Functional scores were assessed using the Lysholm score and the International Knee Documentation Committee (IKDC) score. The minimum followup was 24 months (mean, 45 months; range, 24-96 months).

RESULTS

We observed no differences in the side-to-side KT 2000™ measurements, Lysholm score, or IKDC functional scores based on the preoperative MAD.

CONCLUSIONS

The stability and functional scores after ACL reconstruction were not adversely altered by primary varus alignment. Thus, if there is no medial compartment arthritis or varus thrust, we do not believe a correctional tibial osteotomy is crucial in primary varus knees undergoing ACL reconstruction.

Role of high tibial osteotomy in chronic injuries of posterior cruciate ligament and posterolateral corner

High tibial osteotomy (HTO) is a surgical procedure used to change the mechanical weight-bearing axis and alter the loads carried through the knee. Conventional indications for HTO are medial compartment osteoarthritis and varus malalignment of the knee causing pain and dysfunction. Traditionally, knee instability associated with varus thrust has been considered a contraindication. However, today the indications include patients with chronic ligament deficiencies and malalignment, because an HTO procedure can change not only the coronal but also the sagittal plane of the knee. The sagittal plane has generally been ignored in HTO literature, but its modification has a significant impact on biomechanics and joint stability. Indeed, decreased posterior tibial slope causes posterior tibia translation and helps the anterior cruciate ligament (ACL)-deficient knee. Vice versa, increased tibial slope causes anterior tibia translation and helps the posterior cruciate ligament (PCL)-deficient knee. A review of literature shows that soft tissue procedures alone are often unsatisfactory for chronic posterior instability if alignment is not corrected. Since limb alignment is the most important factor to consider in lower limb reconstructive surgery, diagnosis and treatment of limb malalignment should not be ignored in management of chronic ligamentous instabilities. This paper reviews the effects of chronic posterior instability and tibial slope alteration on knee and soft tissues, in addition to planning and surgical technique for chronic posterior and posterolateral instability with HTO.

Proximal tibial opening wedge osteotomy as the initial treatment for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study

BACKGROUND

Nonoperative treatment of posterolateral knee injuries tends to yield poor results. In patients with chronic posterolateral knee injuries, failure to correct genu varus alignment will often result in failure of the posterolateral knee repair or reconstruction.

PURPOSE

To prospectively assess the functional outcomes of patients with combined grade 3 posterolateral instability and genu varus alignment initially treated with a proximal tibial opening wedge osteotomy.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

Twenty-one patients with combined chronic posterolateral corner deficiency and genu varus alignment were initially treated with a proximal tibial opening wedge osteotomy and observed prospectively. Second-stage ligamentous reconstruction was performed in patients with continued clinical and functional instability after the osteotomies had healed and they had undergone at least 3 months of rehabilitation.

RESULTS

At a mean follow-up of 37 months, 8 of 21 patients (38%) had sufficient improvement in knee function that a subsequent posterolateral corner reconstruction was not necessary. There was a significant difference in coronal alignment between the preoperative and postoperative mechanical axis action point. There were no significant differences in the preoperative and postoperative posterior tibial slope. Thirteen patients underwent a second-stage ligament reconstruction at an average of 13.8 months after the initial osteotomy procedure. Final postoperative Cincinnati Knee Rating System scores were significantly lower for those patients who required a subsequent posterolateral corner reconstruction than for those patients who did not have a reconstruction. The P value for the preoperative differences between groups was not significant (P = .11). Seven of 9 patients with high-velocity knee injuries required a second-stage reconstruction. Ten of 14 patients (71%) with multiligament knee injuries required a posterolateral corner reconstruction. In contrast, 4 of 6 patients (67%) with an isolated posterolateral corner injury did not require a second-stage ligament reconstruction.

CONCLUSION

Proximal tibial opening wedge osteotomy can be an effective first method of treatment for patients with chronic combined posterolateral knee injuries and genu varus alignment. Patients with low-velocity knee injuries and isolated chronic posterolateral knee injuries may not require a second-stage soft tissue ligament reconstruction after healing the osteotomy and undergoing a program of rehabilitation.

The coronal plane high tibial osteotomy. Part 1: a clinical and radiographic analysis of intermediate term outcomes

The coronal plane high tibial osteotomy is a novel technique that is used to treat tibiofemoral malalignment. The authors hypothesize that the coronal plane high tibial osteotomy is (1) efficacious in treating both varus and valgus tibiofemoral malalignment; (2) does not alter the slope of the proximal tibia; and (3) does not alter the relationship between the patella and tibial tubercle. A retrospective review of 25 patients with tibiofemoral malalignment (19 varus/6 valgus) treated with a coronal plane osteotomy with a minimum of 2-year follow-up was performed. A Kaplan-Meyer survival curve was performed using knee arthroplasty and a Hospital for Special Surgery (HSS) knee score <70 as failure criteria. The Insall-Salvati ratio and the proximal tibial slope were measured. A p value of 0.05 was considered significant. At 60-month follow-up, knees with initial varus malalignment had an 84% survival rate using both knee arthroplasty and the HSS score as endpoints. Knees with initial valgus malalignment had an 84 and 60% survival rate using knee arthroplasty and the HSS score as endpoints, respectively. There was no statistically significant change in the Insall-Salvati ratio and proximal tibial slope after coronal plane osteotomy. The coronal plane osteotomy is efficacious in treating varus and valgus tibiofemoral malalignment and does not alter the patellar-tibial tubercle relationship or the posterior tibial slope [case series (level of evidence: IV)].

Osteotomy for the Early Varus Arthritic Knee

High tibial osteotomy is a well-established procedure for the management of medial compartment arthritis that is currently experiencing a resurgence in popularity. A number of techniques have been described, with the ultimate goal of obtaining appropriate alignment to provide pain relief and functional improvement over a long-term period. Appropriate patient selection and careful surgical technique is necessary to achieve these goals with a minimal risk of complication. Newer technology such as computer navigation promises to improve the overall accuracy of the procedure. The need for alignment correction in combination with ligament reconstruction and chondral resurfacing surgery will increase the indications for this procedure. This article discusses the techniques available for high tibial osteotomy, the results and relative advantages of each, and the appropriate surgical technique to achieve optimal results while minimizing complications.

Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust

BACKGROUND

The purpose of this study was to assess the functional outcome of opening wedge high tibial osteotomy (HTO) in a young, active group of patients with instability rather than osteoarthritis.

METHODS

The results of 17 opening wedge HTOs in 16 patients with a symptomatic hyperextension-varus thrust were evaluated. Functional results were evaluated according to the activity scoring system of Tegner and Lysholm and using a 5-point visual analogue scale to assess change in knee stability and satisfaction. Radiographs were analyzed to determine changes in femorotibial and mechanical axis alignment, tibial slope, and patellar height.

RESULTS

Patients were followed for a mean of 56 months. All patients had an increase in their activity score postoperatively. Nine patients rated their symptoms as significantly better and seven as somewhat better. All but one were satisfied with the surgery. Femorotibial axis alignment was changed to a mean of 6 degrees valgus, mechanical axis alignment was corrected to a mean of 46% toward the lateral compartment, posterior tibial slope was increased a mean of 8 degrees, and the ratio of patellar height was decreased a mean of 0.17.

CONCLUSION

Opening wedge HTO can produce good functional and radiographic results in selected patients with a symptomatic thrust.

Arthritis and osteotomies in anterior cruciate ligament reconstruction

Unfortunately, young patients with active life-styles who present with an ACL-deficient knee and early evidence of arthritis remain a very difficult population to treat. Arthroscopic ACL reconstruction is a proven and effective way to treat patients with anterior knee instability [2]. In addition, numerous authors have demonstrated that knee osteotomies are effective in addressing isolated medial or lateral compartment degenerative disease, even in the presence of anterior knee instability [7, 9, 22, 43]. A comprehensive evaluation of pain, alignment, and stability are necessary in order to formulate the best treatment plan for each patient. Patients with combined chronic instability secondary to ACL insufficiency and unicompartmental arthritis will generally benefit from arthroscopic debridement, ACL reconstruction, knee osteotomy, or any combination thereof. Expectations of patients should be managed according to their underlying pathology, and this is a critical component for the success of the surgery. Most patients will get some degree of symptomatic relief and functional improvement. A return to competitive or high-level sports is an unrealistic goal, however, and should be discouraged.

Management of unicompartmental arthritis in the anterior cruciate ligament-deficient knee

There exists a group of patients who are difficult to manage because they have both anterior knee instability secondary to anterior cruciate ligament deficiency and unilateral degenerative joint disease. A large majority of these patients report a history of previous meniscal injury or meniscectomy after knee trauma at a relatively young age. Active patients who report symptomatic knee instability or pain associated with athletics or activities of daily living after conservative treatment may be indicated for surgery. Current endoscopic methods of anterior cruciate ligament reconstruction result in low patient morbidity, the elimination of anterior knee instability, and a timely return of function. Osteotomies about the knee joint are an effective means of treating unicompartmental knee arthrosis. Long-term studies have demonstrated that knee osteotomy is a good surgical option for patients with unicompartmental arthritis who are considered too young for total knee arthroplasty. We describe a comprehensive treatment approach to the patient with anterior cruciate ligament deficiency and isolated medial or lateral osteoarthritis. An assessment of pain symptoms, instability symptoms, and lower extremity alignment is used to formulate a treatment plan.

High tibial osteotomy alone or combined with ligament reconstruction in anterior cruciate ligament-deficient knees

High tibial osteotomy (HTO) is widely accepted as a treatment option in patients with medial unicompartimental osteoarthritis (OA) and varus morphotype of the knee. We increasingly see younger patients with a chronic anterior instability, an additional varus morphotype and beginning medial OA. Treatment options for these patients are not clear up to now. In this clinical study we compare for the first time three different treatment rationales and introduce a concept of symptom-oriented surgery in young patients with medial OA and chronic anterior instability.

MATERIALS/METHODS

Between 1984 and 1994 30 patients were treated with a medical unicompartimental OA and chronic anterior instability of the knee. Patients were grouped into three different groups according to treatment. 1) only HTO was performed. 2) HTO and simultaneously an ACL-reconstruction and 3) HTO and 6-12 months later an ACL-reconstruction was performed. 27/30 patients were available for follow-up. All patients had an arthroscopy before surgery. Evaluation was done according to the IKDC-protocol and X-ray documentation.

RESULTS

Pain was a major problem in all patients. None of them was completely pain-free. 8/27 patients had pain even with light activities. This included 1/11 patients of group 1, 3/8 of group 2 and 4/8 of group 3. 9/27 patients had stable knee joints with a Lachman-test of 3-5 mm. No patient had a Lachman test < 3 mm. 3/11 patients of group 1, 3/8 of group 2 and 2/8 of group 3 had a Lachman test of 5-10 mm. A positive pivot-shift could be found in 9/27 patients. 2/11 of group 1, 4/8 in group 2 and 3/8 in group 3. The overall IKDC-score improved in 23/27 patients, one patient remained unchanged, two deteriorated. Radiologically a slight progression of OA could be seen in all patients. Radiological signs of OA and pain did not show any correlation. There was, however, a significant rate of postoperative complications involving 4/11 patients of group 1 and 3/8 of group 3. There were 6 major complications in 5/8 patients in group 2. Nevertheless overall patient satisfaction was high. 25/27 patients would undergo the procedure again.

CONCLUSION

HTO is a good treatment option for younger patients with medial OA and chronic anterior instability of the knee. These patients pose a high challenge to diagnostic and operative skills of the surgeon. Main symptoms of these patients have to be analysed clearly in terms of instability and pain. In patients aged 40 and older an HTO alone is an excellent treatment option with reproducibly good results. In younger patients we advise an HTO first. If instability persists, an ACL-reconstruction can be done 6-12 months later. One has to be aware that a simultaneous combined procedure has a significant complication rate. Hence if a simultaneous combined treatment is planned the surroundings including surgical technique, rehabilitation and patient compliance have to be ideal. These young patients need an activity counselling in order to realise that their knee joint has suffered significantly from the injury and ongoing high physical demands on their knee joint.