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High Tibial Osteotomy, Over-the-Top Revision ACL Reconstruction plus Extra-Articular Tenodesis for ACL-Deficient Varus Knees in Middle Aged Patients


Stefano Zaffagnini, MD, Prof.
ITALY

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High Tibial Osteotomy, Over-the-Top Revision ACL Reconstruction plus Extra-Articular Tenodesis for ACL-Deficient Varus Knees in Middle Aged Patients

Giulio Maria Marcheggiani Muccioli, MD, PhD, Associate Professor, ITALY Stefano Zaffagnini, MD, Prof., ITALY Alberto Grassi, PhD, ITALY Tommaso Bonanzinga, MD, PhD, ITALY Danilo Bruni, MD, ITALY Francesco Iacono, MD, PhD, ITALY Costanza Musiani, MD, ITALY Marco Nitri, MD, ITALY Maurilio Marcacci, MD, ITALY

Istituto Ortopedico Rizzoli, Bologna, ITALY

2013 Congress   Paper Abstract   2013 Congress   Not yet rated

 

Anatomic Location

Knee

Anatomic Structure

Bones Cartilage Ligaments

Diagnosis / Condition

Osteoarthritis Instability

Sports Medicine

Outcome Studies

Treatment / Technique

Osteotomy Repair / Reconstruction Single Bundle

Cartilage

Cartilage Treatment

Ligaments

ACL

Summary: Lateral closing wedge HTO in addition to hamstrings ACL revision (Over-the-Top plus extra-articular tenodesis) showed 82% satisfactory results (normal aligned and stable knee) in the treatment of chronic ACL-deficient varus knees.

Introduction

High tibial osteotomy (HTO) is a widely accepted treatment for symptomatic medial osteoarthritis with lower estremity varus alignment. In young active patients this pattern could be caused by unoperated anterior cruciate ligament (ACL) rupture or ACL reconstruction failure. ACL-deficiency is also responsible of the high frequency of medial meniscal lesion requiring meniscectomy, that are proven to worsen the chondral wearing of medial compartment. Combined ACL reconstruction and HTO represents a feasible salvage procedure in such complex patients. The purpose of this work is to investigate the clinical and radiographic outcomes of varus knees with failed anterior cruciate ligament (ACL) reconstruction treated with valgus high tibial osteotomy combined to an Over-the-Top revision ACL reconstruction plus extra-articular tenodesis.

Methods

In a consecutive series we treated 36 young patients (age at surgery 40.1±8.1 years old) who had chronic ACL deficiency and lower limb varus angulation. The surgery was performed at a mean of 9.8±3.6 years later the first ACL reconstruction. A 90% follow-up was obtained at a mean of 6.5 ±2.7 year after surgery. Fifty-three percent of these patients (N=17) had a partial lost of the medial meniscus and 70 % (N=22) had marked articular cartilage damage (Outerbridge grade 3 or 4) in the medial compartment at the time of the surgery. All patients were treated with arthroscopic OVER-THE-TOP single-bundle ACL reconstruction plus extra-articular lateral tenodesis with autologous hamstrings [1] and lateral closing wedge high tibial osteotomy [2].

Results

At follow-up, a reduction in pain was found in 94 % (N=30) of knees, with a mean VAS for pain score improvement from 73.2.±12.0 to 42.1±25.0. The other mean subjective scores greatly improved at follow-up: EQ5D from 0.62±0.23 to 0.89±0.13 (p=0.0001); Tegner activity from 3 (range 2-4) to 5 (range 4-5)(P=0.0012); subjective IKDC from 58.0±12.2 to 72.0±16.5 (p=0.0001). Objective IKDC improved from 1B, 13C, 18D, to 15A, 14B, 3D. The mean objective ligament laxity (as measured by KT-1000 side-to-side difference) resulted 2.7±1.0 mm at final FU, with only three patients reporting a value >5 mm (9%, all of them presented a varus alignment). The femoral-tibial angle (FTA) changed from 178.5° ±1.5° to 172.9±6.13° (p=0.0014) and the hip-knee-ankle angle (HKA) changed from 186.2°±2.7° to 179.6°±5.7° (p=0.0015). The posterior tibial slope (PTS) decreased of 1.2°. Six patients (18%) presented varus alignment at final FU. Significant changes of radiographic IKDC score were reported only for medial compartment (p=0.0230), changing from 1A, 12B, 19C to 10B, 14C, 8D. Positive correlation was found between KT-1000 side-to-side difference and PTS (p= .0441; r= .64)

Conclusion

Lateral closing wedge HTO in addition to hamstrings ACL revision (OVER-THE-TOP plus extra-articular tenodesis) showed 82% satisfactory results (normal aligned and stable knee) in the treatment of chronic ACL-deficient varus knees. The findings of this study are comparable to the literature [3]. In conclusion we recommend this combined procedure to manage varus angulated knees with combined chronic ACL deficiency.

References:
1. Marcacci M, et al. Am J Sports Med. 2009;37(4):707-14.
2. Marcacci M, et al. Oper Tech Orthop. 2006;17:22-28.
3. Noyes FR, et al. Am J Sports Med. 2000;28(3):282-96.