Dataset Information

Surgical Techniques, Outcomes, Indications, and Complications of Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Revision Surgery: A Systematic Review.

ABSTRACT:

Background

The incidence of primary anterior cruciate ligament reconstruction (ACLR) failure ranges from 10 to 20% in the USA. Many patient and surgical factors may lead to re-rupture after ACLR. Some authors have suggested that not correcting excessive posterior tibial slope may be a significant contributing factor to ACLR failure.

Purposes

We sought to systematically review the literature on outcomes, indications, and complications in patients undergoing simultaneous high tibial osteotomy (HTO) and ACLR revision.

Methods

PubMed, Medline, and Embase were searched in February 2018 for articles addressing simultaneous HTO and ACLR revision in skeletally mature patients. Major orthopedic conferences were screened in duplicate to find gray literature. All studies were assessed using the Methodological Index for Non-Randomized Studies. Descriptive statistics are presented where applicable.

Results

Seven studies satisfied inclusion. Seventy-seven patients underwent combined HTO and ACLR revision. The main indications were a posterior slope of more than 12° or severe varus malalignment. Graft types included hamstring tendon autograft (58.4%; n?= 45) and quadriceps tendon graft (16.9%; n?= 13). Mean delay between primary and revision surgery was 9 years. Rehabilitation protocol dictated return to running at 4 months and return to sport at 4 to 9 months. Visual analog scale pain scores reduced on average by 30 points. Subjective International Knee Documentation Committee, Tegner-Lysholm, and Tegner activity scores also improved. Fifty-eight percent (35/60) of patients showed osteoarthritis signs post-operatively. One patient (1.3%) received an arthroscopic arthrolysis of adhesions for stiffness. There were no reported incidences of graft re-rupture.

Conclusion

This systematic review found that the use of HTO for ACLR revision produces good post-operative functional outcomes, low complication rates, and no reported re-ruptures. The main indications for combined HTO with ACLR revision was a posterior slope of more than 12° or severe varus malalignment. Future studies with large sample sizes and long-term follow-up are required to corroborate these results.

SUBMITTER: Gupta A

PROVIDER: S-EPMC6609638 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Publications

Surgical Techniques, Outcomes, Indications, and Complications of Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Revision Surgery: A Systematic Review.

Gupta Arnav A Tejpal Tushar T Shanmugaraj Ajaykumar A Horner Nolan S NS Simunovic Nicole N Duong Andrew A Ayeni Olufemi R OR

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20180924 2

<h4>Background</h4>The incidence of primary anterior cruciate ligament reconstruction (ACLR) failure ranges from 10 to 20% in the USA. Many patient and surgical factors may lead to re-rupture after ACLR. Some authors have suggested that not correcting excessive posterior tibial slope may be a significant contributing factor to ACLR failure.<h4>Purposes</h4>We sought to systematically review the literature on outcomes, indications, and complications in patients undergoing simultaneous high tibial ...[more]

PMID: 31327950

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Project description:BackgroundWe 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.MethodsThis 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.ResultsThere 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.ConclusionsSimultaneous 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.

Project description:Excessive posterior tibial slope (PTS) is a recognized risk factor for failure of anterior cruciate ligament reconstruction (ACLR) and should be considered when planning a revision ACLR. A tibial supra-tubercular deflexion osteotomy can correct excessive PTS with simultaneous or staged ACLR. There are only a handful of technical descriptions offering insight on the respective authors’ approach at reducing PTS, all of which vary greatly in their methods. The authors describe a surgical technique using a proximal tibial supra-tubercular deflexion osteotomy in patients with persistent knee instability, a history of at least one failed ACLR, and a PTS greater than 12°. This surgery is not recommended in patients with significant genu recurvatum (>10°), significant varus, or severe tibiofemoral osteoarthritis. Technique Video Video 1 This technique video shows important aspects of preoperative planning and the surgical technique for supra-tubercular deflexion osteotomy divided into 10 steps. We start by emphasizing how the height of the osteotomy wedge resected is dependent on tibial width in the sagittal plane. This is clearly shown in the third slide, where Patient A has a longer tibial width in the sagittal plane (green line), when compared to Patient B, and requires a larger anterior wedge resection of 11.7 mm to achieve a target slope of 5°. Patient B, who has the same posterior tibial slope as patient A (17°), requires a shorter anterior wedge resection of 8.4 mm to correct to 5° of posterior tibial slope. The third and fourth slides of the video also depict two ways to calculate the osteotomy wedge height. We recommend calculating osteotomy wedge height (WH) using the following formula, which requires only measurement of the PTS and tibial width (TW): Osteotomy WH X = (TW)∙ tan (resection ∠) where the resection angle (12° in these examples) is the angle of the wedge needed to be removed in order to achieve the desired final PTS (5° in these examples). The second way is an approximation formula, which is derived from tangent but does not include trigonometry in the final formula. The final few slides demonstrate the 10 steps of our technique, which include: 1) scope, hardware removal, and tunnel grafting, 2) midline incision with medial and lateral flaps, 3) location of distal insertion of patellar tendon, 4) placement of 4 pins in a triangular fashion, 5) sawblade cuts between pins, 6) removal of bone wedge, 7) cleaning of site with curette, 8) drill posterior cortex, 9) closing of osteotomy in extension, and 10) fixation with staples.

Project description:PurposeTo evaluate the biomechanical profile of subcortical backup fixation (subcortical button [SB]) in anterior cruciate ligament (ACL) reconstruction as compared with a bicortical post and washer (BP) and suture anchor (SA) when used with interference screw (IS) primary fixation and to evaluate the utility of backup fixation for tibial fixation with extramedullary cortical button primary fixation.MethodsFifty composite tibias with polyester webbing-simulated graft were used to test constructs across 10 methods. Specimens were separated into the following groups (n = 5): 9-mm IS only, BP (with and without graft and IS), SB (with and without graft and IS), SA (with and without graft and IS), extramedullary suture button (with and without graft and IS), and extramedullary suture button with BP as backup fixation. Specimens were tested under cyclic loading and then loaded to failure. Maximal load at failure, displacement, and stiffness were compared.ResultsWithout a graft, the SB and BP had similar maximal loads (802.46 ± 185.18 N vs 785.67 ± 100.96 N, P = .560), and both were stronger than the SA (368.13 ± 77.26 N, P < .001). With graft and an IS, there was no significant difference in maximal load between the BP (1,461.27 ± 173.75 N), SB (1,362.46 ± 80.47 N), and SA (1,334.52 ± 195.80 N). All backup fixation groups were stronger than the control group with IS fixation only (932.91 ± 99.86 N, P < .001). There was no significant difference in outcome measures between the extramedullary suture button groups with and without the BP (failure loads of 721.39 ± 103.32 N and 718.15 ± 108.61 N, respectively).ConclusionsSubcortical backup fixation in ACL reconstruction has similar biomechanical properties to current methods and is a viable backup fixation alternative. Backup fixation methods work synergistically with IS primary fixation to strengthen the construct. There is no advantage to adding backup fixation to extramedullary button (all-inside) primary fixation when all suture strands are secured to the extramedullary button.Clinical relevanceThis study provides evidence that subcortical backup fixation is a viable alternative for surgeons during ACL reconstruction.

Dataset Information

Surgical Techniques, Outcomes, Indications, and Complications of Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Revision Surgery: A Systematic Review.

Background

Purposes

Methods

Results

Conclusion

Publications

Surgical Techniques, Outcomes, Indications, and Complications of Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Revision Surgery: A Systematic Review.

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