CORR Insights1: Coronal Limb Alignment and Indications
for High Tibial Osteotomy in Patients Undergoing Revision
John P. Albright MD
Received: 29 July 2013/Accepted: 12 August 2013/Published online: 28 August 2013
? The Author(s) 2013. This article is published with open access at Springerlink.com
Where Are We Now?
The current study by Won and colleagues concluded that
patients undergoing revision ACL surgery have a greater
incidence of significant varus alignment compared with
patients undergoing primary ACL reconstruction. The
authors also observed that this varus alignment was asso-
ciated with meniscal pathology and degenerative changes
of the knee. The report of varus alignment provides an
interesting observation that goes a step beyond the findings
of the Multi-center Anterior (C)ruciate Revision Study
(MARS) , but leads to more questions than answers. The
article does not tell us about the results of performing a
high tibial osteotomy at the time of the revision ACL. It
merely points out that these patients are potential candi-
dates for such a procedure.
The strength of the manuscript is that it reminds us that
varus malalignment is a potential variable to be mindful of.
It also serves to warn surgeons they should be aware of
possible failure of the graft, and continuing pain related to
medial compartment degeneration. Won and colleagues’
attention to detail in establishing an effective protocol for
the long-leg films is important because standing long-leg
radiographs are fickle in terms of being able to demonstrate
consistently the true amount of coronal plane alignment.
Where Do We Need to Go?
with varus thrust (without medial compartment arthritis) the
stability and functional scores were not adversely affected by
primary varus alignment. Kim and colleagues  also
reported that aside from extreme cases where varus thrust is
noted, (in addition to the post meniscectomy changes) the
radiographic features of unicompartmental osteoarthritis are
insufficient to be associated with graft failure.
Another MARS study  indicated that a significant
number of revision surgeries were related to technical
difficulties in graft tunnel placement in the primary pro-
cedure. This raises a number of questions. Was the
degenerative process and progressive varus at fault in
causing the ligament failure in the other revision surgeries
not related to graft tunnel placement? Which patients need
proximal tibial osteotomies at the time of revision ACL
surgery? Should a high tibial osteotomy be performed to
avoid postsurgical medial joint line pain? Will concomitant
realignment increase the chance of establishing stability or
would staging the two procedures not only eliminate the
This CORR Insights1is a commentary on the article ‘‘Coronal Limb
Alignment and Indications for High Tibial Osteotomy in Patients
Undergoing Revision ACL Reconstruction’’ by Won and colleagues
available at: DOI: 10.1007/s11999-013-3185-2.
The author certifies that he, or a member of his immediate family, has
no funding or commercial associations (eg, consultancies, stock
ownership, equity interest, patent/licensing arrangements, etc.) that
might pose a conflict of interest in connection with the submitted
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research1editors and board members are
on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the
opinion or policy of CORR1or the Association of Bone and Joint
This CORR Insights1comment refers to the article available at DOI:
J. P. Albright (&)
Department of Orthopaedic Surgery and Rehabilitation, The
University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242, USA
Clin Orthop Relat Res (2013) 471:3512–3513
and Related Research®
A Publication of The Association of Bone and Joint Surgeons®
risks associated with the combined procedure in a signifi- Download full-text
cant number of patients, but also prolong the function of
these patients by putting off a realignment procedure with a
time-and-demand-limited survival curve?
How Do We Get There?
We need to perform a large prospective case-control study
observing primary ACLs over a long period of time, and
separately analyzing those who have initial varus with
intraarticular pathology from patients who do not. We need
to conduct followup analysis to determine whether the
varus indeed increases the risk of ligament failure. Such a
study should also observe the progression of osteoarthritis
and secondary development of varus deformity so we could
get a better picture of the natural history.
Another study that would help fill in our current
knowledge gap would be examining the existence of
medial compartment osteoarthritis in an ACL deficient
knee that has already had a failure of a primary ACL
surgery. It should be determined, in the setting of a large
randomized controlled trial, whether those patients who
undergo a high tibial osteotomy at the same time as ACL
revision surgery will fare better than those who have an
ACL revision without an osteotomy.
This should be a very well-defined study group with
radiograph-based alignment protocol similar to the one
used in the current study. How much varus is necessary to
change the odds ratio for ACL revision alone? Is varus
thrust indeed the only game changer? Will staging the
stabilization and the realignment procedure provide the
patient with a greater number of years of satisfactory
function? These important questions remain unanswered.
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author(s) and the source are credited.
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Volume 471, Number 11, November 2013Coronal Limb Alignment 3513