Summary

Anterior closing wedge high tibial osteotomy with revision anterior cruciate ligament reconstruction will restore knee stability and improves function, but less than half of the patients will return to impact sports.

Abstract

Purpose. Increased Posterior Tibial Slope (PTS) is a proven risk factor for both native and grafted ACL insufficiency. PTS correction using anterior closing wedge high tibial osteotomy (ACW-HTO) is a validated procedure in revision ACL Reconstruction (ACLR). The authors evaluated the impact of the combined ACW-HTO and at least a second revision ACLR on knee stability, function, and sports performances in a large series of patients.

Methods

A total of 64 patients who underwent a second (or more) revision ACLR from 01-06-2015 to 01-06-2019, and had a PTS >12° were planned to undergo an additional ACW-HTO. The mean age was 29.60 ± 6.31 years old, and preoperative PTS was 13.79 ± 1.50 °. The cases were analyzed at a mean follow-up of 2.96 ± 0.83 (2–5 years). At the last follow-up available, the rate of patients returning to impact sports (analysis based on UCLA score), ACL graft status (MRI), IKDC, Lysholm scores, and Laxity measurement using (GNRB) knee arthrometer were recorded.

Results

The total number of patients practicing impact sports and high impact sports were; preinjury 43 and 30, respectively; preoperatively 3 and 0, respectively, and postoperatively 31 and 12, respectively. At the last follow-up, the UCLA score reported = 8 in 48.43 % of the patients, and only 22 patients returned to their preinjury level of activity. At a minimum of 2 years follow-up, there was clinical improvement in the IKDC scores from preoperative 37.98 ± 12.48 to postoperative 69.06 ± 12.30, Lysholm scores from preoperative 51.94 ± 14.03 to postoperative 74.45 ± 11.44 points, and improvement in the UCLA activity score (p < 0.001). However, this clinical improvement did not equate to the preinjury level in all the scores (P< 0.001). The preinjury IKDC and Lysholm scores were 76.98 ± 11.71, and 89.26 ± 8.91, respectively.The mean ? anterior knee laxity, using GNRB Knee arthrometer at 134 N and 250 N, were -3.63 ± 0.16 and -4.03 ± 0.18 mm, respectively. There were 3 cases of re-rupture with severe explosive pivot on clinical examination. None of these cases were revised as per patient’s preference. Increased knee recurvatum was observed in a third of the patients, but all were asymptomatic.

Conclusion

In the setting of chronic ACL deficient knees, posterior tibial slope reduction (ACW-HTO) with revision anterior cruciate ligament reconstruction will restore knee stability and improves function with an acceptable rate of specific complications. Increased knee recurvatum was observed in a third of the patients, but all were asymptomatic. And less than half of the patients were able to return to high-impact sports.