Coronal Limb Alignment and Indications for High Tibial Osteotomy in Patients Undergoing Revision ACL Reconstruction

Joint Reconstruction Center, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, (463-707), Republic of Korea.
Clinical Orthopaedics and Related Research (Impact Factor: 2.88). 07/2013; 471(11). DOI: 10.1007/s11999-013-3185-2
Source: PubMed

ABSTRACT Failed ACL reconstruction frequently is accompanied by irreparable medial meniscal tear and/or visible osteoarthritis (OA) in the medial tibiofemoral joint. Thus, assessment for the presence of varus malalignment is important in caring for patients in whom revision ACL reconstruction is considered.
We determined whether patients undergoing revision ACL reconstruction (1) have more frequent varus malalignment coupled with more severe degrees of medial meniscal injury and/or medial tibiofemoral OA, and (2) would meet potential indications for high tibial osteotomy more frequently than patients undergoing primary ACL reconstruction.
We compared 58 patients undergoing revision ACL reconstruction and 116 patients undergoing primary ACL reconstruction. The mechanical tibiofemoral angle and the weight loading line (%) of the knee were measured. Additionally, radiographic degrees of OA in the tibiofemoral joints, and meniscal conditions were assessed. Then, proportions of potential candidates for high tibial osteotomy between the two groups were compared based on the following indications: (1) weight loading line less than 5%, (2) weight loading line less than 25% and medial tibiofemoral OA Kellgren-Lawrence Grade 3 or greater, or (3) weight loading line less than 25% and Kellgren-Lawrence Grade 2 medial tibiofemoral OA plus subtotal or total medial meniscectomy status.
The revision ACL reconstruction group had more frequent varus malalignment in terms of proportion of knees with more varus mechanical tibiofemoral angle than varus 5° (19% versus 8%, p = 0.029) and knees with weight loading line less than 25% (22% versus 9%, p = 0.011). This group also had more frequent high-grade injury of the medial meniscus (34% versus 16%, p = 0.007) and tended to have more frequent higher-grade radiographic OA at the medial tibiofemoral joint (19% versus 9%, p = 0.076). The percentage of patients meeting potential indications for high tibial osteotomy was greater in this group (14% versus 2%, p = 0.003).
We found that many patients undergoing revision ACL surgery may be reasonable candidates for concurrent high tibial osteotomy to address concomitant alignment and OA issues in the medial compartment. However, whether that additional intervention is offset by added risk and morbidity should be the focus of a future study, as it cannot be answered by a study of this design.
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.


Available from: Chong Bum Chang, Feb 15, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: Anterior cruciate ligament (ACL) tears are a common injury, particularly in the athletic and youth populations. The known association between ACL injury and subsequent osteoarthritis (OA) of the knee merits a more in-depth understanding of the relationship between the ACL-injured knee and osteoarthritis. ACL injury, especially with concomitant meniscal or other ligamentous pathology, predisposes the knee to an increased risk of osteoarthritis. ACL insufficiency results in deterioration of the normal physiologic knee bending culminating in increased anterior tibial translation and increased internal tibial rotation. This leads to increased mean contact stresses in the posterior medial and lateral compartments under anterior and rotational loading. However, surgical reconstruction of the ACL has not been shown to reduce the risk of future OA development back to baseline and has variability based on operative factors of graft choice, timing of surgery, presence of meniscal and chondral abnormalities, and surgical technique. Known strategies to prevent OA development are applicable to patients with ACL deficiency or after ACL reconstruction and include weight management, avoidance of excessive musculoskeletal loading, and strength training. Reconstruction of the ACL does not necessarily prevent osteoarthritis in many of these patients and may depend on several external variables.
    01/2015; 2015:928301. DOI:10.1155/2015/928301
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study was undertaken to determine clinical outcome after medial opening wedge osteotomy with Tlocking plate, with two- year follow up. Twenty-two patients (22 knees) who underwent medial opening wedge osteotomy with T-locking plate (stainless steel 316L, 6 holes) for treatment of varus malalignment of the leg between March 2005 and April 2008 were included in the study. The amount of correction ranged from 7° to 19° (mean, 9.77°). Clinical and radiographic findings were evaluated with VAS and the Lysholm score at sixth, twelfth and twenty- fourth months. Follow-up ranged from 18 to 37 months (mean, 2.1 years). Significant reduction was observed of VAS, from 4 (range: 3.5-5) to almost free of symptoms (1.0 to 0.5) at the twentyfourth month follow-up (P<0.01). Good results were achieved in the Lysholm score (P<0.01). Medial opening wedge osteotomy with T-locking plate is safe and efficient procedure for corrective varus deformity of knee.
    03/2014; 8(1):50-5. DOI:10.5704/MOJ.1403.019