Combined anterior cruciate ligament reconstruction and high tibial osteotomy

This chapter describes in detail the indications, surgical planning, and step-by-step procedure for combined anterior cruciate ligament (ACL) reconstruction and open wedge high tibial osteotomy (HTO).

All patients undergo preoperative planning, clinical examination, and patient-specific workup. Preoperative measurement of the degree of varus knee alignment is critical, and the correction angle is determined preoperatively for each case. Important factors that could influence prognosis are type of varus alignment (i.e., primary, double, or triple varus ), age, cartilage condition, and contralateral knee alignment.

A combined ACL reconstruction and HTO should be performed in the following scenarios:

• Severe varus alignment or hyperextension (more than 20 degrees)

• Double or triple varus

• Symptomatic medial knee arthritis in a varus aligned knee

• Varus alignment with lateral joint opening

• Varus alignment with external tibial rotation

• Varus thrust

• Varus alignment with concomitant medial meniscus deficiency or chondral/osteochondral defects

• Varus alignment with concomitant increased posterior tibial slope

• Normal aligned knee with at least 2 degrees of varus comparing to the healthy contralateral knee

Short soft-tissue grafts or quadriceps tendon grafts are recommended when compared with bone plug grafts, as they allow for an easier and more versatile technique.

The femoral side of the ACL reconstruction is performed as usual.

A slightly more distal osteotomy cut allows for a longer ACL tibial tunnel.

A hybrid tibial fixation is especially preferred in these cases to improve graft fixation in the shorter tibial tunnel.

The posterior tibial slope is essential for both ligament function and knee kinematics and it should be assessed preoperatively and intraoperatively. The surgeon must control for small variations and avoid increasing the posterior tibial slope during the procedure, as it could influence graft survival.

The osteotomy should always be performed before the ACL tibial tunnel.

The most anterior screw of the tibial plate should be placed carefully or not placed at all. Some of the locking osteotomy plates allow for axial deviations of the anterior screw, avoiding the tibial tunnel.

Try to avoid increasing the posterior tibial slope.