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Intraoperative Laximetry-Based Selective Transtibial Anterior Cruciate Ligament Reconstruction Concomitant With Medial Open Wedge High Tibial Osteotomy for Treating Varus Knee Osteoarthritis With Anterior Cruciate Ligament Deficiency.

ABSTRACT: High tibial osteotomy (HTO) is used in the treatment of varus knee osteoarthritis (KOA) in young and active patients. At times, a concomitant anterior cruciate ligament (ACL) deficiency is found, and there is no conclusive evidence comparing the osteotomy options for an ACL-deficient knee despite the popularity of medial opening-wedge (MOW) HTO in varus KOA with ACL deficiency. To minimize the incidence of an unnecessary ACL reconstruction with MOW-HTO, we developed an intraoperative laximetry-based selective technique for transtibial ACL reconstruction concomitant with MOW-HTO using a sterilizable metal laximeter. To successfully use the device required for this procedure, surgeons must understand the proper techniques. Hence, this Technical Note aims to give a comprehensive description of the technique.

SUBMITTER: Takahashi T

PROVIDER: S-EPMC9243668 | biostudies-literature |

REPOSITORIES: biostudies-literature

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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.

Dataset Information

Intraoperative Laximetry-Based Selective Transtibial Anterior Cruciate Ligament Reconstruction Concomitant With Medial Open Wedge High Tibial Osteotomy for Treating Varus Knee Osteoarthritis With Anterior Cruciate Ligament Deficiency.

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