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The Role of High Tibial Osteotomy in ACL Reconstruction in Knees with Coronal and Sagittal Plane Deformity

  • ACL: Risk Factors, Outcomes, Preventions (R Gallo, Section Editor)
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Abstract

Purpose of Review

Coronal and sagittal malalignment in the setting of anterior cruciate ligament (ACL) deficiency alters knee biomechanics and is shown to increase stress and strain on the native ACL and on the ACL graft during reconstruction. The purpose of this review was to determine the role and indications of high tibial osteotomy to correct coronal and/or sagittal plane malalignment with ACL reconstruction.

Recent Findings

Recent literature illustrates that an increase in varus malalignment and increased posterior tibial slope increases the biomechanical stress that is seen in a native or reconstructed ACL graft. It has been proposed to correct the sagittal and coronal malalignment by employing a high tibial osteotomy either prior to or at the time of ACL reconstruction to correct these deformities and to decrease the stress placed on the reconstructed ACL graft.

Summary

The use of high tibial osteotomy for deformity correction creates a more stable knee for ACL reconstruction and has been shown to have good outcomes with regard to post-operative pain, stability, satisfaction scores, and function.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Jan de Pol G, Arnold MP, Verdonschot N, van Kampen A. Varus alignment leads to increased forces in the anterior cruciate ligament. Am J Sports Med. 2009;37(3):481–7. https://doi.org/10.1177/0363546508326715.

    Article  Google Scholar 

  2. •• Hinckel BB, Demange MK, Gobbi RG, Pecora JR, Camanho GL. The effect of mechanical varus on anterior cruciate ligament and lateral collateral ligament stress: finite element analyses. Orthopedics. 2016;39(4):729–36. https://doi.org/10.3928/01477447-20160421-02The current study analyzed changes in anterior cruciate ligament (ACL) and lateral collateral ligament stress as a result of mechanical varus. In an exploratory pilot study, progressive mechanical varus was introduced to a male finite element model of the lower limb at different knee flexion angles. Nine situations were analyzed (combinations of 0°, 30°, and 60° knee flexion and 0°, 5°, and 10° varus). The ACL stress was measured via changes in section force, von Mises stress, and fiber stress. Lateral collateral ligament stress was measured via changes in section force. For all 3 measures of the ACL, maximum stress values were found in extension, stress decreased with flexion, and the effect of varus introduction was most significant at 30° flexion. With 60° flexion, varus introduction produced a decrease in section force and von Mises stress and a small increase in fiber stress. In all situations and stress measures except fiber stress at 60° flexion, stress was concentrated at the posterolateral bundle. For the lateral collateral ligament, the introduction of 5° and 10° varus caused an increase in section force at all degrees of flexion. Stress in the ligament decreased with flexion. Mechanical varus of less than 10° was responsible for increased ACL stress, particularly at 0° and 30° knee flexion, and for increased lateral collateral ligament stress at all degrees of flexion. Stress was mostly concentrated on the posterolateral bundle of the ACL.

    Article  Google Scholar 

  3. Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Row JP. Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament reconstructed patient. Am J Sports Med. 2013;41(12):2800–4. https://doi.org/10.1177/0363546513503288.

    Article  PubMed  Google Scholar 

  4. Lahav A, Burks R. Evaluation of the failed ACL reconstruction. Sports Med Arthrosc. 2005;13(1):8–16. https://doi.org/10.1097/01.jsa.0000147193.95513.84.

    Article  Google Scholar 

  5. Crawford SN, Waterman BR, Lubowitz JH. Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy. 2013;29(9):1566–71. https://doi.org/10.1016/j.arthro.2013.04.014.

    Article  PubMed  Google Scholar 

  6. Trojani C, Dijan SA, Hulet PJF, et al. Causes for failure of ACL reconstruction and influence of menisectomies after revision. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):196–201. https://doi.org/10.1007/s00167-010-1201-6.

    Article  PubMed  Google Scholar 

  7. Li Y, Zhang H, Zhang J, Li X, Song G, Feng H. Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis n young patietns with anterio cruciate deficient knees: a systematic review. Arthroscopy. 2015;31:3. https://doi.org/10.1016/j.arthro.2014.07.026.

    Article  CAS  Google Scholar 

  8. Kannus P, Järvinen M. Posttraumatic anterior cruciate ligament insufficiency as a cause of osteoarthirits in a knee joint. Clin Rheumatol. 1989;8:251–60. https://doi.org/10.1007/BF02030082.

    Article  CAS  PubMed  Google Scholar 

  9. Cantin O, Magnussen RA, Corbi F, et al. The role of high tibial osteotomy in the treatment of knee laxity: a comprehensive review. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):3026–37.

    Article  CAS  Google Scholar 

  10. Brouwer GM, Van Tol AW, Bergink AP, Belo JN, Bernsen R, et al. Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum. 2007;56(4):1204–11. https://doi.org/10.1002/art.22515.

    Article  CAS  PubMed  Google Scholar 

  11. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28(3):282–96. https://doi.org/10.1177/03635465000280030201.

    Article  CAS  PubMed  Google Scholar 

  12. •• Cantivalli A, Rosso F, Bonasia DE, Rossi R. High tibial osteotomy and anterior ligament reconstruction/revision. Clin Sports Med. 2019;38(3):417–33. https://doi.org/10.1016/j.csm.2019.02.008High tibial osteotomy (HTO) is a procedure commonly used to treat medial early osteoarthritis (OA) in young and active patients. Combined HTO and anterior cruciate ligament reconstruction (ACL-R) is indicated in patients with medial OA and varus alignment (primary, double, or triple varus) associated with ACL tear with symptomatic anteroposterior instability, failed ACL-R, or increased posterior tibial slope (PTS). A PTS greater than 12 is a risk factor for ACL-R failure and should be modified. There are different surgical techniques to perform a concomitant HTO and ACL-R. Opening wedge and closing wedge HTO are the most commonly performed, but there is no evidence supporting the superiority of one procedure over the others. For ACL-R, soft tissue autograft or allograft is commonly used in association with anatomic reconstruction. There are few studies on combined HTO and ACL-R with short follow-up and few patients. However, most of these studies reported good outcomes, with complication rates similar to isolated or staged ACL-R.

    Article  PubMed  Google Scholar 

  13. •• Crawford M, Lee DH, Amendola A. Surgical management and treatment of the anterior cruciate ligament deficient knee with malalignment. Clin Sports Med. 2017;36(1):119–33. https://doi.org/10.1016/j.csm.2016.08.006Malalignment can increase stress on anterior cruciate ligament (ACL) reconstruction, contributing to recurrent instability. Varus malalignment can lead to overload of the medial compartment and symptomatic arthritis. Realignment osteotomy can reduce symptoms of ACL instability and unload or reduce mechanical wear of the medial compartment. Correction of varus malalignment can improve outcomes of revision ACL reconstruction. Changes of tibial slope can affect symptomatic ACL laxity.

    Article  PubMed  Google Scholar 

  14. • Schuster P, Geßlein M, Schlumberger M, Mayer P, Richter J. The influence of tibial slope on the graft in combined high tibial osteotomy and anterior cruciate ligament reconstruction. Knee. 2018;25(4):682–91. https://doi.org/10.1016/j.knee.2018.04.007Background: Young patients with severe medial osteoarthritis, varus malalignment and insufficiency of the anterior cruciate ligament (ACL) are difficult to treat. The tibial slope has gained attention with regard to osteotomies and ligamentous instability. The purpose was to evaluate the outcome of combined high tibial osteotomy (HTO), ACL reconstruction and chondral resurfacing (CR, abrasion plus microfracture), and to analyze graft failure rates with regard to the tibial slope. Methods: Fifty cases (48.9 ± 5.4 years) of combined HTO, ACLR and CR were retrospectively analyzed with regard to survival, functional outcome (subjective International Knee Documentation Committee (IKDC) examination form) and subjective satisfaction. The tibial slope was determined on lateral radiographs and analyzed with regard to its influence on graft functionality at the time of hardware removal. Results: Follow-up rate was 100% after 5.6 ± 1.6 years. No arthroplasties were performed. Subjective IKDC score was 70 ± 18, and 94% were satisfied with the result. The graft was intact in 39 cases (78%), and non-functional in 11 cases (22%). No significant changes were present in pre- and postoperative tibial slope (P= 0.811). Graft insufficiency was strongly dependent on tibial slope, with a failure rate of 7% in cases of postoperative tibial slope b 7.5°, 24% in cases of 7.5–12.5°, and 36% in cases of N 12.5°.Conclusion: Combined HTO, ACLR, and CR is an effective treatment in these cases. The graft failure rate increases with an increase in tibial slope, in particular when exceeding 12.5°.Level of evidence: Case series, Level 4.

    Article  PubMed  Google Scholar 

  15. Dejour D, Saffarini M, Demey G, et al. Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2846–52. https://doi.org/10.1007/s00167-015-3758-6.

    Article  PubMed  Google Scholar 

  16. Chae CL, Yoon SY, Sung DC, Seung HJ, Mun HB, Seon JP, et al. Does posterior tibial slope affect graft rupture following anterior cruciate ligament reconstruction? Arthroscopy. 2018;34(7):2152–5. https://doi.org/10.1016/j.arthro.2018.01.058.

    Article  Google Scholar 

  17. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P. Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):170–80. https://doi.org/10.1007/s00167-012-2087-2.

    Article  PubMed  Google Scholar 

  18. Won HH, Chang CB, Je MS, et al. Coronal limb alignment and indications for high tibial osteotomy in patients undergoing revision ACL reconstruction. Clin Ortho Relat Res. 2013;471(11):3504–11. https://doi.org/10.1007/s11999-013-3185-2.

    Article  Google Scholar 

  19. •• Stride D, Wang J, Horner NS, et al. Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(4):1320–31. https://doi.org/10.1007/s00167-019-05379-5Purpose: the purpose of this study was to systematically review the existing literature reporting surgical outcomes of simultaneous high tibial osteotomy (HTO) and anterior cruciate ligament reconstruction (ACLR) in anterior cruciate ligament deficient (ACLD) knees. Methods: This study was conducted per the methods of the Cochrane Handbook for Systematic Reviews of Intervention, with findings reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data was extracted. Studies reporting post-operative outcomes following simultaneous HTO and ACLR in ACLD knees were included. Results: The search identified 515 studies, of which 18 (n = 516) were included. The mean MINORS scores for non-comparative and comparative studies were 11.6 ± 1.34 and 17.3 ± 1.9, respectively. Simultaneous HTO and ACLR resulted in improved functional subjective patient outcomes across a variety of scales. Simultaneous HTO and ACLR was effective in correcting varus angulation, with the post-operative mechanical angle ranging from 0.3 to 7.7° valgus. The reported complication rate ranged from 0 to 23.5%. Across six studies, a total of 13 (6.5%) patients required revision HTO; while across four studies, 20 (17.5%) patients had failure of the ACL graft, with one receiving revision ACLR. Conclusions: Combined HTO and ACLR may be indicated in patients with ACLD knees with varus angulation. This systematic review found that the combined surgery resulted in significant improvement in post-operative functional subjective outcomes. However, it remains unclear if HTO with ACLR is superior to ALCR or HTO alone due to the lack of comparative studies. Overall, HTO with ACLR was found to have low rates of complications, re-ruptures, and need for revision surgery. This review found that patients continued to have progression of OA despite combined HTO with ACLR. Future research is required to better understand the effects of combined HTO and ACLR compared to ACLR or HTO alone and to evaluate the long-term post-operative progression of medial compartment OA following combined HTO and ACLR. Level of evidence IV.

    Article  PubMed  Google Scholar 

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  1. Department of Orthopaedics, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA

    Michal Klek & Aman Dhawan

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  1. Michal Klek
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Klek, M., Dhawan, A. The Role of High Tibial Osteotomy in ACL Reconstruction in Knees with Coronal and Sagittal Plane Deformity. Curr Rev Musculoskelet Med 12, 466–471 (2019). https://doi.org/10.1007/s12178-019-09589-9

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