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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

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Project description:In performing medial open-wedge high tibial osteotomy, it is recommended not to alter the posterior tibial slope. However, it remains unclear whether the osteotomy inclination angle affects the posterior tibial slope in the sagittal plane. This study aimed to verify how anterior or posterior osteotomy inclination angle affects the tendency of change in the posterior tibial slope and to conduct quantitative analysis of the extent to which the posterior tibial slope changes according to the degree of the osteotomy inclination angle change in MOWHTO. Computed tomography images of 30 patients who underwent MOWHTO were collected. Three-dimensional models of preoperative original tibia were reconstructed, and virtual osteotomies were performed. The sagittal osteotomy inclination angles formed by the osteotomy line and the medial tibial plateau line were classified as positive in case of anteriorly inclined osteotomy and negative in case of posteriorly inclined osteotomy. Thirteen osteotomies were performed for each tibial model at intervals of 5° from - 30° to 30°. The posterior tibial slope was assessed, and the proportional relationship between the sagittal osteotomy inclination angle and the posterior tibial slope change was analyzed. The posterior tibial slope changed significantly after osteotomy (p < 0.001), except for the cases where the sagittal osteotomy inclination angles were 5°, 0°, and - 5°. Anteriorly and posteriorly inclined osteotomy caused increase and decrease in the posterior tibial slope, respectively. As the inclination angle increased by 1°, the posterior tibial slope increased by 0.079° in anterior inclination osteotomy, while in posterior inclination osteotomy, as the inclination angle decreased by 1°, the posterior tibial slope decreased by 0.067°. The osteotomy inclination angle in the sagittal plane significantly affected the posterior tibial slope. When there was an inclination angle occurred between the osteotomy line and the medial tibial plateau line in the sagittal plane, the posterior tibial slope changed after MOWHTO. The posterior tibial slope tended to increase in anteriorly inclined osteotomy and decrease in posteriorly inclined osteotomy. The change in the posterior tibial slope was proportionally related to the absolute value of the osteotomy inclination angle.

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

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