Tibial Tubercle Preserving Anterior Closing Wedge Proximal Tibial Osteotomy and ACL Tunnel Bone Grafting for Increased Posterior Tibial Slope in Failed ACL Reconstructions

ABSTRACT: Anterior cruciate ligament reconstruction (ACLR) failure is multifactorial, but it is known that increased posterior tibial slope (PTS) leads to a greater likelihood of ACLR failure. This technical note describes the senior author’s technique for performing an anterior closing wedge proximal tibial osteotomy, in which the osteotomy is made proximal to the tibial tubercle. This procedure is the first part of a staged surgery for patients with multiple failed ACLRs and increased sagittal plane PTS. Debridement of osteolytic reconstruction tunnels with bone grafting is also undertaken in preparation for a second-stage revision ACLR. Technique Video Video 1 Proximal tibial closing wedge osteotomy with tibial tubercle sparing and bone grafting. In a patient with multiple failed anterior cruciate ligament (ACL) reconstructions and increased posterior tibial slope (PTS) in the right knee, a proximal tibial closing wedge osteotomy is performed with bone grafting as a first stage to maximize the chances of success of a subsequent second stage ACL reconstruction. Examination under anesthesia reveals 3+ positive pivot-shift and Lachman tests. An anterior midline incision is made, and subcutaneous skin flaps develop medially and laterally. A scalpel and Cobb elevator are used to develop subperiosteal flaps laterally to the proximal tibiofibular joint and medially to the posteromedial aspect of the tibia. The patellar tendon is carefully outlined and protected, as the tibial tubercle will be preserved. Arthroscopy is then performed to address any intraarticular pathology and debride osteolytic bone tunnels from previous ACL reconstructions. Two guide pins are then placed parallel to the joint line at the inferior extent of the desired osteotomy. After confirming their position extending to the posterior tibial cortex fluoroscopically, two additional pins are drilled, parallel to the joint line, at the anterior extent of the planned osteotomy. These are angled such that they will meet the first two pins at the posterior tibial cortex, and fluoroscopy is used for verification of position. An ACL saw is then used to cut the anterior tibial cortex colinear with the inferior and superior guide pins, the desired wedge of bone is removed with curettes and rongeurs, and the guide pins are removed. To verify enough bone has been removed, a curette is inserted into the posterior extent of the wedge, and a lateral fluoroscopic image is taken. The wedge is then gently closed and a bump placed under the heel. The closed osteotomy is secured with several large staples, and anteroposterior and lateral radiographs confirm position of hardware. Bone grafting of the tibial and femoral tunnels is accomplished with autologous bones from the osteotomy and allograft bone matrix.

SUBMITTER: Floyd E 

PROVIDER: S-EPMC8556534 | biostudies-literature |

REPOSITORIES: biostudies-literature