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Anterior Cruciate Ligament Reconstruction Combined with High-Tibial Osteotomy, Autologous Chondrocyte Implantation, Microfracture, Osteochondral, and/or Meniscal Allograft Transplantation
Introduction
Knees with chronic anterior cruciate ligament (ACL) tears often have degenerative changes. If these changes are severe, cartilage restorative procedures may be necessary in addition to ACL reconstruction (ACLR). The question in such cases is whether to perform the restorative procedures simultaneously with the ACLR. If they are not done simultaneously, the question becomes one of proper sequencing and the necessary time interval between procedures.
Individualization
Cases requiring combined procedures are inherently complicated. Some patients will need ACLR plus one other restorative procedure, but some patients may need a total of three or four such procedures. Decision making can be helped by the application of certain principles, which will be discussed later. However, each patient’s individual characteristics should be carefully studied and weighed in decision making. The patient’s pathology is most important, but work and life circumstances must be carefully considered to avoid disruption to the extent possible.
Surgeon Factors
The surgeon must also realistically weigh his or her own skill and experience. When in doubt, it is better to sequence procedures than to perform difficult procedures simultaneously, with which the surgeon may have limited experience. Patients generally prefer simultaneity, but this should not be done if it will subject the patient to greater risk of failure.
Success Rates
In the literature and in our experience, success rates with appropriate combined procedures have been high. Table 102.1 summarizes the relevant literature. Surgery and aftercare must be meticulous. Reimbursement may not be commensurate with the amount of work performed. Not all surgeons will wish to perform these types of procedures. However, if the procedures are satisfactorily performed, and if the patients are carefully chosen, the results can be gratifying.
TABLE 102.1
Success Rates for Combined Procedures
| Authors | Year | Success Rate |
|---|---|---|
| ACLR With Microfracture | ||
| Gudas et al. | 2013 | 28/32 (88%) patients had normal or nearly normal IKDC scores at 3 years |
| Osti et al. | 2010 | 23/25 (92%) patients had normal or nearly normal IKDC scores at 2 years and 72% at 5 years |
| ACLR With ACI | ||
| Amin et al. | 2006 | 7/9 patients improved; 2/9 described no improvement |
| Dhinsa et al. | 2015 | 16 out of 22 patients reported improved symptoms |
| ACLR With MAT | ||
| Cameron and Saha | 1997 | 80% (4/5) of patients who had ACLR + MAT had good to excellent results; 86% (6/7) of those who had ACLR, MAT, and HTO had good to excellent results |
| Graf et al. | 2004 | 2/8 patients had normal, 5/8 had nearly normal, and 1 had abnormal scores on the IKDC symptom scale. 6/8 were pleased with the outcome. Improved swelling, pain, stability, and knee function |
| Rueff et al. | 2006 | IKDC improved 36 points on average postoperatively; 87% (7/8) considered surgery a success |
| Sekiya et al. | 2003 | 86% patients normal or nearly normal on IKDC |
| Wirth et al. | 2002 | Recorded substantial improvement in both Lysholm and Tegner scores |
| Yoldas et al. | 2003 | 19/20 patients reported normal or nearly normal scores on IKDC |
| ACLR With OATS | ||
| Gudas et al. | 2013 | 29/33 (88%) patients had normal or nearly normal IKDC scores at 3 years |
| Bobic | 1996 | 10/12 patients promised a response at 2-year follow-up |
| Klinger et al. | 2003 | 81% normal or nearly normal scores on IKDC |
| ACLR With HTO | ||
| Bonin et al. | 2004 | At 12 years, 5/30 (17%) patients progressed one arthritis grade, 47% returned to intensive sports, and 37% returned to moderate sports |
| Lattermann and Jakob | 1996 | 3/8 patients had pain even with light activity |
| Neuschwander et al. | 1993 | 4/5 patients had good or excellent results; one had fair |
| Noyes et al. | 1993 | 94% of patients reported significant improvement |
| Noyes et al. | 2000 | Pain was reduced in 71% of knees; 71% of patients reported their knees as very good/normal or good |
| Schuster et al. | 2016 | In 23 patients, IKDC scores improved from preoperatively to 1 year, to 3 years, to 5 years |
| Stutz et al. | 1996 | 8/13 patients had normal or nearly normal subjective IKDC scores |
| Trojani et al. | 2014 | 23/29 patients resumed sports, with 45% competitive sports; 70% had normal or nearly normal IKDC scores |
| Williams et al. | 2003 | Found statistically significant increases in Lysholm, HSS, Tegner score; 92% of patients were satisfied |
| Zaffagnini et al. | 2013 | 32 patients, all scores significantly improved; two failures |
ACI , Autologous chondrocyte implantation; ACLR , anterior cruciate ligament reconstruction; HSS , Hospital for Special Surgery; HTO , high-tibial osteotomy; IKDC , International Knee Documentation Committee; MAT , meniscal allograft transplantation; OATS , osteochondral autograft transfer system.
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