Systematic Review
Clinical Outcome of Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction for Medial Compartment Osteoarthritis in Young Patients With Anterior Cruciate LigamenteDeficient Knees: A Systematic Review Yue Li, M.D., Hui Zhang, M.D., Jin Zhang, M.D., Xu Li, M.D., Guanyang Song, M.D., and Hua Feng, M.D.
Purpose: High tibial osteotomy (HTO) has been a well-established procedure addressing tibiofemoral osteoarthritis in young patients. However, for physically active patients with concomitant anterior cruciate ligament (ACL) injury, simultaneous HTO and ACL reconstruction is considered a salvage procedure. Controversy exists regarding the subjective and objective evaluations and the prevalence of complications. Methods: A search in the Medline database and of major orthopaedic journals was performed. Articles were included if they met the specific inclusion and exclusion criteria. Anterior knee laxity, osteoarthritis, subjective outcomes, sagittal and coronal alignment, and complications were analyzed. Results: A total of 721 articles were retrieved from the search, and 11 eligible studies (218 knees) were included for evaluation. Postoperatively, the mean side-to-side difference measured by KT-1000 (MEDmetric, San Diego, CA) was 2.4 mm, and 85.7% of patients gained grade A or B stability according to International Knee Documentation Committee evaluation. Medial compartment osteoarthritis showed a tendency of alleviation. Regardless of the scoring system, all subjective evaluations showed improvement and most of the participants returned to recreational sports. All cases of varus malalignment were corrected, with a mean value of 7.13 . The most prevalent complication was deep venous thrombosis (7.7%). Conclusions: Simultaneous HTO and ACL reconstruction was a salvage procedure for physically active young patients because it provided satisfactory restoration of anterior stability, alleviation of medial compartment osteoarthritis, improvement of subjective evaluations, and a predictable return to recreational sports. Level of Evidence: Level IV, systematic review of Level III and IV studies.
C
hronic anterior cruciate ligament (ACL) injury has been proved to be implicated in the development of tibiofemoral osteoarthritis (OA).1-6 Regardless of surgical intervention, the risk of cartilage loss increases by 19 times for the medial femoral condyle 7 to 11 years after injury.5 Furthermore, patients who undergo delayed anterior cruciate ligament reconstruction (ACLR) are more susceptible to an increased incidence of medial meniscal lesions,7 which are managed by concomitant partial meniscectomy or complete
From the Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received April 2, 2014; accepted July 25, 2014. Address correspondence to Hua Feng, M.D., Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14275/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.07.026
meniscectomy in most cases.8,9 It has been corroborated that meniscectomy is a definite risk factor for the early onset of medial OA,10-12 with an odds ratio of 3.54.13 Medial compartment OA is also a very common condition in patients with varus malalignment.14 In addition, meniscectomy aggravates the varus alignment.15 In the meantime, the varus alignment was observed to potentially compromise the ACL or the ACL graft by increasing the ligament tension.12,16,17 Accordingly, the combination of the 2 pathologies of medial compartment OA and ACL injury is one of the “most difficult diagnostic and treatment dilemmas that [a] clinician may be required to manage.”4 Commonly occurring in young individuals, acute ACL injuries tend to predispose patients to an early onset of OA at the age of 30 to 50 years.3 Although ACLR provides restoration of anterior knee stability, the development of OA after ACLR seems to undergo little intervention.18,19 Valgus high tibial osteotomy (HTO) has been a widely accepted treatment for medial
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 3 (March), 2015: pp 507-519
507
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Y. LI ET AL.
compartment OA in young patients12,14,20-22 because it yields satisfactory postoperative subjective scores and reduction of OA, slightly decreased physical activity,21 and significantly higher range of motion than knee arthroplasty.21,23 Since the combination of ACLR and HTO was first described by O’Neill and James24 in 1992, several authors have reported the clinical outcome of simultaneous combined procedures.1,2,4,12,22,24-31 However, the indications and benefits of the procedure remain controversial. The purpose of this study was to systematically review the publications on simultaneous ACLR and HTO for young patients with medial compartment OA and ACL-deficient knees to answer the following questions: (1) Can anterior knee stability be restored after combined surgery? (2) What degree of change of the medial compartment OA can be expected? (3) What is the magnitude of subjective evaluation after the combined procedure? (4) What is the effect of posterior tibial slope (PTS) on anterior tibial translation after the operation? (5) What is the appropriate indication for simultaneous combined surgery?
Methods Literature Research We searched the Medline database through the PubMed interface in March 2014 to identify all studies about the clinical outcome of simultaneous HTO and ACLR for the treatment of medial compartment OA and anterior knee laxity. A search of major orthopaedic journals was also performed: The American Journal of Sports Medicine; Arthroscopy; Knee Surgery, Sports Traumatology, Arthroscopy; The Journal of Bone & Joint Surgery; and Clinical Orthopaedics and Related Research. The keywords were “high tibial osteotomy” or “HTO” and “anterior cruciate ligament” or “ACL.” In addition, the references of all included studies were reviewed. Data Extraction The inclusion criteria were (1) English-language original articles published from January 1990 to March 2014, (2) isolated reports of the subjective and objective outcomes of simultaneous HTO and ACLR, (3) studies in which all patients were skeletally mature, and (4) studies with more than 2 years’ follow-up. Articles were excluded if (1) they included patients with posterior cruciate ligament or posterolateral corner injuries; (2) they were reviews, meta-analyses, case reports, nonhuman studies, or technical notes; and (3) they were studies that were later updated with longerterm follow-up or a larger cohort. All studies retrieved from the search engines were initially checked manually by 2 authors (Y.L. and G.S.) reading the titles. The abstracts of the remaining studies were then read. If it
was uncertain from the abstract whether the study met the inclusion criteria, the full text of the study was read. All included studies were assessed for the level of evidence according to the definition published in The Journal of Bone & Joint Surgery.32 Demographic data consisted of knees enrolled, knees evaluated, distribution of gender, age at surgery, time from injury to surgery, mean follow-up time, and previous procedures (Table 1). Operative procedure data included the graft choice, extra-articular procedure, graft size, femoral and tibial fixation method, osteotomy method, and fixation method (Table 2). Summaries of the rehabilitation protocol (Table 3), results of instrumented anterior knee laxity (Table 4), assessment of OA (Table 5), subjective evaluations and return to sports (Table 6), and changes in coronal- and sagittal-plane alignment (Table 7) were retracted from the included studies. Complications such as stiffness, patella infera, and nonunion were also recorded.
Results Study Selection The initial research resulted in 721 articles. After the comprehensive review of titles, abstracts, and full texts, 712 articles were excluded. All references of the 9 included articles were further screened by abstract or full text, and 2 more eligible studies were identified. In total, 11 articles were included in this systematic review (Fig 1). Of the 11 studies, 8 were Level IV case-series studies and 3 were Level III retrospective comparative studies. All of the case-series studies reported the clinical outcome of simultaneous HTO and ACLR. The 3 retrospective comparative studies reported isolated subjective and objective outcomes after simultaneous HTO and ACLR. Study Demographic Data In total, 218 knees (170 male and 48 female knees) were evaluated at a mean follow-up of 5.8 years. The mean age at surgery was 34.4 years. Of the 11 articles, 6 reported the exact time from injury to surgery, with a mean of 9.0 years. Because the 3 comparative studies only had documentation of the number of previous surgical procedures per patient instead of isolated surgical history data of the simultaneous group,28,30,31 only the number of surgeries per patient was calculated in our review. Among the 11 studies evaluated, each patient underwent 1.2 previous surgical procedures. Among the 174 previous surgical procedures reported in detail by 8 studies, 103 (59.2%) were medial meniscectomies, 44 (25.3%) were ACLR or combined ACLR and extra-articular procedures, 4 (2.3%) were HTOs, 3 (1.7%) were lateral meniscectomies, 2 (1.1%)
Table 1. Patient Demographic Characteristics Date 2010
Level of Evidence IV
Knees Enrolled 4
Knees Evaluated 4
M:F 2:2
Age at Surgery, yr (range) 45 (37-50)
Time From Injury to Surgery (Range) NP
2004
IV
40
30
23:7
30 (18-41)
Boss et al.26
1995
IV
34
27
22:5
36 (19-55)
Dejour et al.2
1994
IV
50
44
28:16
29 (18-42)
>2 mo in 22 patients 2 mo in 5 patients 6 yr (0-20 yr)
Lattermann and Jakob28 Neuschwander et al.29
1996
III
NP
8
5:3
32 (20-38)
67 mo
1993
IV
5
5
4:1
27.2 (21-35)
Noyes et al.30 O’Neill and James24
1993 1992
III IV
NP 10
16 10
15:1 5:5
31 (19-41) 32.1
Trojani et al.22
2014
IV
34
29
20:9
43 (25-56)
14 yr (2-29 yr)
Williams et al.31 Zaffagnini et al.12
2003
III
NP
13
18:7
33.5 (28-41)
14.7 yr (1-30 yr)
2013
IV
32
32
28:4
40.1 (27-54)
NP
7 yr (1-21 yr)
NP
107.5 mo (4-330 mo) NP
Mean Follow-up (Range) 28 mo (10-45 mo) 12 yr (6-16 yr)
75 mo (31-166 mo) 3.6 yr (1-11 yr)
5.8 yr (18 mo to 10 yr)* 2.5 yr (2-3 yr)
45 mo (25-62 mo) 3 yr
6 yr (25 mo to 12 yr)
38.2 mo 6.5 yr (4-10 yr)
Previous Procedures 2 partial meniscectomy 19 MM 1 LM 1 lateral meniscal repair 3 ACLR 2 lateral tenodesis þ MCL repair 4 total MM 13 ACLR or repair þ extraarticular procedure 1 ACLR alone 27 MM 2 medial meniscal repair NP 3 total MM 2 partial MM 2.6 procedures per patienty 10 MM 6 extra-articular ACLR 19 MM 7 BPTB 1 artificial ACLR 2 Lemaire procedure 3 lateral tenodesis 3 McIntosh procedure 1 LM 4 other procedures 1.4 procedures per patienty
SIMULTANEOUS HTO AND ACL RECONSTRUCTION
Study Akamatsu et al.25 Bonin et al.1
13 ACLR 17 partial MM 1 partial LM 1 lateral meniscus suture 4 HTO 3 other procedures
509
BPTB, boneepatellar tendonebone; F, female; LM, lateral meniscectomy; M, male; MCL, medial collateral ligament; MM, medial meniscectomy; NP, not provided. *The study by Lattermann and Jakob was a comparative study with 2 groups: HTO combined with ACLR and HTO alone. Only the overall follow-up time of 5.8 years was reported, although no significant difference between these 2 groups was detected. y These 2 studies were comparative studies on combined ACL and HTO procedures with other procedures. Only the overall number of previous procedures was documented.
510
Table 2. Operative Procedure Data
Study Akamatsu et al.25
Extra-Articular Procedure None
Bonin et al.1
BPTB autograft
25 Lemaire procedures33
NP
Femoral Fixation EndoButton (Smith & Nephew Endoscopy, Andover, MA) Press fit
Boss et al.26
13 artificial grafts
None
NP
Screw or staples
Dejour et al.2
14 BPTB autografts BPTB autograft
BPTB autograft
Graft Size NP
Tibial Fixation Spiked staples
HTO Method OW
Interference screw
5 OW
Screw or staples
25 CW 3 OW
28 Lemaire procedures 6 other procedures None
NP
Wire loops and screws
NP
NP
BPTB autograft
None
NP
Interference screw
Noyes et al.30
BPTB autograft
NP
O’Neill and James24 Trojani et al.22
BPTB autograft
All Losee procedures34 None
NP
Interference screw and staples Screw
3 tenodeses
NP
None
Extra-articular augmentation
Zaffagnini et al.12
Staples, AO T-plate, or semitubular plate
Wire loops and screws
7 OW
Staples
37 CW
Neuschwander et al.29
Williams et al.31
Staples
24 CW
NP
10 OW 17 CW
12 BPTB autografts 17 four-strand hamstring tendon autografts 2 BPTB autografts 2 four-strand hamstring tendon autografts 9 BPTB allografts Hamstring autografts
HTO Fixation Method TomoFix (Synthes, West Chester, PA)
Button and suture
NP
Interference screw Interference screw and staples Natural insertion of patellar tendon NP
NP
NP
7 mm
Natural insertion of hamstring
BPTB, boneepatellar tendonebone; CW, closing wedge; NP, not provided; OW, opening wedge.
CW
OW: staples or external fixator CW: angulated buttress plate Staples or tension band and screw
CW
Angled side plate
CW
Staples
OW
Puddu plate
NP
CW
Staples and plates
Staples
CW
Krackow staple
Y. LI ET AL.
Lattermann and Jakob28
Graft 4-strand hamstring tendon autograft
511
SIMULTANEOUS HTO AND ACL RECONSTRUCTION Table 3. Summary of Rehabilitation Protocol Study Akamatsu et al.25 Bonin et al.1 Boss et al.26 Dejour et al.2 Lattermann and Jakob28 Neuschwander et al.29 Noyes et al.30
O’Neill and James24 Trojani et al.22 Williams et al.31 Zaffagnini et al.12
ROM Exercise First day Immediately Immediately
Partial Weight Bearing 2 wk 8 wk NP
Full Weight Bearing 4 wk NP After dismission
Return to Sports 6 mo NP 3 mo: recreational sports 6-9 mo: demanding sports Immediately 8 wk NP Partial weight bearing on 2 crutches and ROM exercise for 4-6 wk 2 cylinder cast for 6 wk NP NP NP 3 early CPM NP 2 wk NP Immediately Immediately to fourth week: 12 wk NP toe touch Fourth to sixth week: onefourth body weight Sixth to eighth week: one-half body weight NP First day 6 wk NP NP ACLR protocol implemented after satisfactory bony consolidation of osteotomy site 2 wk Immediately to fourth week: NP 5 wk: swimming, stationary toe touch and progression to bike full weight bearing 4 mo: running 8 mo: sports
CPM, continuous passive motion; NP, not provided; ROM, range of motion.
were medial meniscal repairs, and 18 (10.3%) were other procedures (Table 1). Operative Procedure Data and Rehabilitation Protocol Among all 218 knees, 150 ACLs (68.8%) were reconstructed with boneepatellar tendonebone
autografts, 55 (25.2%) with 4-strand hamstring tendon autografts, and 13 (6.0%) with artificial grafts. Extraarticular procedures were performed in 104 knees (47.7%). Of the 218 HTOs, 160 (73.4%) were closingwedge high tibial osteotomies (CWHTOs) and 58 (26.6%) were opening-wedge high tibial osteotomies (OWHTOs). The fixation method for ACLR or HTO
Table 4. Summary of Instrumented Anterior Knee Laxity Anterior Knee Laxity (Side-to-Side Difference) Preoperative Study Akamatsu et al.25 Bonin et al.1 Boss et al.26* Dejour et al.2 Lattermann and Jakob28 Neuschwander et al.29
Noyes et al.30 O’Neill and James24 Trojani et al.22 Williams et al.31 Zaffagnini et al.12
Instrument (Force) NP Lachman test KT-1000 (manual maximum) KT-1000 (manual maximum) Lachman test
Mean, mm (range) 7.5 (4.0 to 9.5) NP NP
A NP NP NP
7
KT-1000 (20 lb) KT-1000 (manual maximum) KT-1000 (manual maximum) KT-1000 (manual maximum) Telos (150 N) Lachman test Lachman test KT-1000 (manual maximum)
Final Follow-up B
Mean, mm (range) 1.0 (0 to 2.0) NP NP
A NP 27 12
NP
3
NP
NP
NP
NP
0
5
3
0
NP
7.8 (5 to 11.5) 10 (6.5 to 12.5)
0 0
3.0 (0 to 6) 3.1 (0 to 5.5)
3 3
1 1
1 1
0 0
NP NP
NP
NP
NP
9
5
5
0
NP
NP
NP
NP
NP
NP NP NP NP
NP NP 0 NP
2.65 (1 to 9) NP NP 2.2 1.0
15 17 11 22
0 0
C
3 2
8
D
2 3
5
B
C
D
0 9
3 1
0 0
P Value NP NP NP NP
NP 8 10 9
5 2 2 1
1 0 0 1
NP NP
Clinical Outcome of Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction for Medial Compartment Osteoarthritis in Young Patients With Anterior Cruciate LigamenteDeficient Knees: A Systematic Review Yue Li, M.D., Hui Zhang, M.D., Jin Zhang, M.D., Xu Li, M.D., Guanyang Song, M.D., and Hua Feng, M.D.
Purpose: High tibial osteotomy (HTO) has been a well-established procedure addressing tibiofemoral osteoarthritis in young patients. However, for physically active patients with concomitant anterior cruciate ligament (ACL) injury, simultaneous HTO and ACL reconstruction is considered a salvage procedure. Controversy exists regarding the subjective and objective evaluations and the prevalence of complications. Methods: A search in the Medline database and of major orthopaedic journals was performed. Articles were included if they met the specific inclusion and exclusion criteria. Anterior knee laxity, osteoarthritis, subjective outcomes, sagittal and coronal alignment, and complications were analyzed. Results: A total of 721 articles were retrieved from the search, and 11 eligible studies (218 knees) were included for evaluation. Postoperatively, the mean side-to-side difference measured by KT-1000 (MEDmetric, San Diego, CA) was 2.4 mm, and 85.7% of patients gained grade A or B stability according to International Knee Documentation Committee evaluation. Medial compartment osteoarthritis showed a tendency of alleviation. Regardless of the scoring system, all subjective evaluations showed improvement and most of the participants returned to recreational sports. All cases of varus malalignment were corrected, with a mean value of 7.13 . The most prevalent complication was deep venous thrombosis (7.7%). Conclusions: Simultaneous HTO and ACL reconstruction was a salvage procedure for physically active young patients because it provided satisfactory restoration of anterior stability, alleviation of medial compartment osteoarthritis, improvement of subjective evaluations, and a predictable return to recreational sports. Level of Evidence: Level IV, systematic review of Level III and IV studies.
C
hronic anterior cruciate ligament (ACL) injury has been proved to be implicated in the development of tibiofemoral osteoarthritis (OA).1-6 Regardless of surgical intervention, the risk of cartilage loss increases by 19 times for the medial femoral condyle 7 to 11 years after injury.5 Furthermore, patients who undergo delayed anterior cruciate ligament reconstruction (ACLR) are more susceptible to an increased incidence of medial meniscal lesions,7 which are managed by concomitant partial meniscectomy or complete
From the Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received April 2, 2014; accepted July 25, 2014. Address correspondence to Hua Feng, M.D., Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14275/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.07.026
meniscectomy in most cases.8,9 It has been corroborated that meniscectomy is a definite risk factor for the early onset of medial OA,10-12 with an odds ratio of 3.54.13 Medial compartment OA is also a very common condition in patients with varus malalignment.14 In addition, meniscectomy aggravates the varus alignment.15 In the meantime, the varus alignment was observed to potentially compromise the ACL or the ACL graft by increasing the ligament tension.12,16,17 Accordingly, the combination of the 2 pathologies of medial compartment OA and ACL injury is one of the “most difficult diagnostic and treatment dilemmas that [a] clinician may be required to manage.”4 Commonly occurring in young individuals, acute ACL injuries tend to predispose patients to an early onset of OA at the age of 30 to 50 years.3 Although ACLR provides restoration of anterior knee stability, the development of OA after ACLR seems to undergo little intervention.18,19 Valgus high tibial osteotomy (HTO) has been a widely accepted treatment for medial
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 3 (March), 2015: pp 507-519
507
508
Y. LI ET AL.
compartment OA in young patients12,14,20-22 because it yields satisfactory postoperative subjective scores and reduction of OA, slightly decreased physical activity,21 and significantly higher range of motion than knee arthroplasty.21,23 Since the combination of ACLR and HTO was first described by O’Neill and James24 in 1992, several authors have reported the clinical outcome of simultaneous combined procedures.1,2,4,12,22,24-31 However, the indications and benefits of the procedure remain controversial. The purpose of this study was to systematically review the publications on simultaneous ACLR and HTO for young patients with medial compartment OA and ACL-deficient knees to answer the following questions: (1) Can anterior knee stability be restored after combined surgery? (2) What degree of change of the medial compartment OA can be expected? (3) What is the magnitude of subjective evaluation after the combined procedure? (4) What is the effect of posterior tibial slope (PTS) on anterior tibial translation after the operation? (5) What is the appropriate indication for simultaneous combined surgery?
Methods Literature Research We searched the Medline database through the PubMed interface in March 2014 to identify all studies about the clinical outcome of simultaneous HTO and ACLR for the treatment of medial compartment OA and anterior knee laxity. A search of major orthopaedic journals was also performed: The American Journal of Sports Medicine; Arthroscopy; Knee Surgery, Sports Traumatology, Arthroscopy; The Journal of Bone & Joint Surgery; and Clinical Orthopaedics and Related Research. The keywords were “high tibial osteotomy” or “HTO” and “anterior cruciate ligament” or “ACL.” In addition, the references of all included studies were reviewed. Data Extraction The inclusion criteria were (1) English-language original articles published from January 1990 to March 2014, (2) isolated reports of the subjective and objective outcomes of simultaneous HTO and ACLR, (3) studies in which all patients were skeletally mature, and (4) studies with more than 2 years’ follow-up. Articles were excluded if (1) they included patients with posterior cruciate ligament or posterolateral corner injuries; (2) they were reviews, meta-analyses, case reports, nonhuman studies, or technical notes; and (3) they were studies that were later updated with longerterm follow-up or a larger cohort. All studies retrieved from the search engines were initially checked manually by 2 authors (Y.L. and G.S.) reading the titles. The abstracts of the remaining studies were then read. If it
was uncertain from the abstract whether the study met the inclusion criteria, the full text of the study was read. All included studies were assessed for the level of evidence according to the definition published in The Journal of Bone & Joint Surgery.32 Demographic data consisted of knees enrolled, knees evaluated, distribution of gender, age at surgery, time from injury to surgery, mean follow-up time, and previous procedures (Table 1). Operative procedure data included the graft choice, extra-articular procedure, graft size, femoral and tibial fixation method, osteotomy method, and fixation method (Table 2). Summaries of the rehabilitation protocol (Table 3), results of instrumented anterior knee laxity (Table 4), assessment of OA (Table 5), subjective evaluations and return to sports (Table 6), and changes in coronal- and sagittal-plane alignment (Table 7) were retracted from the included studies. Complications such as stiffness, patella infera, and nonunion were also recorded.
Results Study Selection The initial research resulted in 721 articles. After the comprehensive review of titles, abstracts, and full texts, 712 articles were excluded. All references of the 9 included articles were further screened by abstract or full text, and 2 more eligible studies were identified. In total, 11 articles were included in this systematic review (Fig 1). Of the 11 studies, 8 were Level IV case-series studies and 3 were Level III retrospective comparative studies. All of the case-series studies reported the clinical outcome of simultaneous HTO and ACLR. The 3 retrospective comparative studies reported isolated subjective and objective outcomes after simultaneous HTO and ACLR. Study Demographic Data In total, 218 knees (170 male and 48 female knees) were evaluated at a mean follow-up of 5.8 years. The mean age at surgery was 34.4 years. Of the 11 articles, 6 reported the exact time from injury to surgery, with a mean of 9.0 years. Because the 3 comparative studies only had documentation of the number of previous surgical procedures per patient instead of isolated surgical history data of the simultaneous group,28,30,31 only the number of surgeries per patient was calculated in our review. Among the 11 studies evaluated, each patient underwent 1.2 previous surgical procedures. Among the 174 previous surgical procedures reported in detail by 8 studies, 103 (59.2%) were medial meniscectomies, 44 (25.3%) were ACLR or combined ACLR and extra-articular procedures, 4 (2.3%) were HTOs, 3 (1.7%) were lateral meniscectomies, 2 (1.1%)
Table 1. Patient Demographic Characteristics Date 2010
Level of Evidence IV
Knees Enrolled 4
Knees Evaluated 4
M:F 2:2
Age at Surgery, yr (range) 45 (37-50)
Time From Injury to Surgery (Range) NP
2004
IV
40
30
23:7
30 (18-41)
Boss et al.26
1995
IV
34
27
22:5
36 (19-55)
Dejour et al.2
1994
IV
50
44
28:16
29 (18-42)
>2 mo in 22 patients 2 mo in 5 patients 6 yr (0-20 yr)
Lattermann and Jakob28 Neuschwander et al.29
1996
III
NP
8
5:3
32 (20-38)
67 mo
1993
IV
5
5
4:1
27.2 (21-35)
Noyes et al.30 O’Neill and James24
1993 1992
III IV
NP 10
16 10
15:1 5:5
31 (19-41) 32.1
Trojani et al.22
2014
IV
34
29
20:9
43 (25-56)
14 yr (2-29 yr)
Williams et al.31 Zaffagnini et al.12
2003
III
NP
13
18:7
33.5 (28-41)
14.7 yr (1-30 yr)
2013
IV
32
32
28:4
40.1 (27-54)
NP
7 yr (1-21 yr)
NP
107.5 mo (4-330 mo) NP
Mean Follow-up (Range) 28 mo (10-45 mo) 12 yr (6-16 yr)
75 mo (31-166 mo) 3.6 yr (1-11 yr)
5.8 yr (18 mo to 10 yr)* 2.5 yr (2-3 yr)
45 mo (25-62 mo) 3 yr
6 yr (25 mo to 12 yr)
38.2 mo 6.5 yr (4-10 yr)
Previous Procedures 2 partial meniscectomy 19 MM 1 LM 1 lateral meniscal repair 3 ACLR 2 lateral tenodesis þ MCL repair 4 total MM 13 ACLR or repair þ extraarticular procedure 1 ACLR alone 27 MM 2 medial meniscal repair NP 3 total MM 2 partial MM 2.6 procedures per patienty 10 MM 6 extra-articular ACLR 19 MM 7 BPTB 1 artificial ACLR 2 Lemaire procedure 3 lateral tenodesis 3 McIntosh procedure 1 LM 4 other procedures 1.4 procedures per patienty
SIMULTANEOUS HTO AND ACL RECONSTRUCTION
Study Akamatsu et al.25 Bonin et al.1
13 ACLR 17 partial MM 1 partial LM 1 lateral meniscus suture 4 HTO 3 other procedures
509
BPTB, boneepatellar tendonebone; F, female; LM, lateral meniscectomy; M, male; MCL, medial collateral ligament; MM, medial meniscectomy; NP, not provided. *The study by Lattermann and Jakob was a comparative study with 2 groups: HTO combined with ACLR and HTO alone. Only the overall follow-up time of 5.8 years was reported, although no significant difference between these 2 groups was detected. y These 2 studies were comparative studies on combined ACL and HTO procedures with other procedures. Only the overall number of previous procedures was documented.
510
Table 2. Operative Procedure Data
Study Akamatsu et al.25
Extra-Articular Procedure None
Bonin et al.1
BPTB autograft
25 Lemaire procedures33
NP
Femoral Fixation EndoButton (Smith & Nephew Endoscopy, Andover, MA) Press fit
Boss et al.26
13 artificial grafts
None
NP
Screw or staples
Dejour et al.2
14 BPTB autografts BPTB autograft
BPTB autograft
Graft Size NP
Tibial Fixation Spiked staples
HTO Method OW
Interference screw
5 OW
Screw or staples
25 CW 3 OW
28 Lemaire procedures 6 other procedures None
NP
Wire loops and screws
NP
NP
BPTB autograft
None
NP
Interference screw
Noyes et al.30
BPTB autograft
NP
O’Neill and James24 Trojani et al.22
BPTB autograft
All Losee procedures34 None
NP
Interference screw and staples Screw
3 tenodeses
NP
None
Extra-articular augmentation
Zaffagnini et al.12
Staples, AO T-plate, or semitubular plate
Wire loops and screws
7 OW
Staples
37 CW
Neuschwander et al.29
Williams et al.31
Staples
24 CW
NP
10 OW 17 CW
12 BPTB autografts 17 four-strand hamstring tendon autografts 2 BPTB autografts 2 four-strand hamstring tendon autografts 9 BPTB allografts Hamstring autografts
HTO Fixation Method TomoFix (Synthes, West Chester, PA)
Button and suture
NP
Interference screw Interference screw and staples Natural insertion of patellar tendon NP
NP
NP
7 mm
Natural insertion of hamstring
BPTB, boneepatellar tendonebone; CW, closing wedge; NP, not provided; OW, opening wedge.
CW
OW: staples or external fixator CW: angulated buttress plate Staples or tension band and screw
CW
Angled side plate
CW
Staples
OW
Puddu plate
NP
CW
Staples and plates
Staples
CW
Krackow staple
Y. LI ET AL.
Lattermann and Jakob28
Graft 4-strand hamstring tendon autograft
511
SIMULTANEOUS HTO AND ACL RECONSTRUCTION Table 3. Summary of Rehabilitation Protocol Study Akamatsu et al.25 Bonin et al.1 Boss et al.26 Dejour et al.2 Lattermann and Jakob28 Neuschwander et al.29 Noyes et al.30
O’Neill and James24 Trojani et al.22 Williams et al.31 Zaffagnini et al.12
ROM Exercise First day Immediately Immediately
Partial Weight Bearing 2 wk 8 wk NP
Full Weight Bearing 4 wk NP After dismission
Return to Sports 6 mo NP 3 mo: recreational sports 6-9 mo: demanding sports Immediately 8 wk NP Partial weight bearing on 2 crutches and ROM exercise for 4-6 wk 2 cylinder cast for 6 wk NP NP NP 3 early CPM NP 2 wk NP Immediately Immediately to fourth week: 12 wk NP toe touch Fourth to sixth week: onefourth body weight Sixth to eighth week: one-half body weight NP First day 6 wk NP NP ACLR protocol implemented after satisfactory bony consolidation of osteotomy site 2 wk Immediately to fourth week: NP 5 wk: swimming, stationary toe touch and progression to bike full weight bearing 4 mo: running 8 mo: sports
CPM, continuous passive motion; NP, not provided; ROM, range of motion.
were medial meniscal repairs, and 18 (10.3%) were other procedures (Table 1). Operative Procedure Data and Rehabilitation Protocol Among all 218 knees, 150 ACLs (68.8%) were reconstructed with boneepatellar tendonebone
autografts, 55 (25.2%) with 4-strand hamstring tendon autografts, and 13 (6.0%) with artificial grafts. Extraarticular procedures were performed in 104 knees (47.7%). Of the 218 HTOs, 160 (73.4%) were closingwedge high tibial osteotomies (CWHTOs) and 58 (26.6%) were opening-wedge high tibial osteotomies (OWHTOs). The fixation method for ACLR or HTO
Table 4. Summary of Instrumented Anterior Knee Laxity Anterior Knee Laxity (Side-to-Side Difference) Preoperative Study Akamatsu et al.25 Bonin et al.1 Boss et al.26* Dejour et al.2 Lattermann and Jakob28 Neuschwander et al.29
Noyes et al.30 O’Neill and James24 Trojani et al.22 Williams et al.31 Zaffagnini et al.12
Instrument (Force) NP Lachman test KT-1000 (manual maximum) KT-1000 (manual maximum) Lachman test
Mean, mm (range) 7.5 (4.0 to 9.5) NP NP
A NP NP NP
7
KT-1000 (20 lb) KT-1000 (manual maximum) KT-1000 (manual maximum) KT-1000 (manual maximum) Telos (150 N) Lachman test Lachman test KT-1000 (manual maximum)
Final Follow-up B
Mean, mm (range) 1.0 (0 to 2.0) NP NP
A NP 27 12
NP
3
NP
NP
NP
NP
0
5
3
0
NP
7.8 (5 to 11.5) 10 (6.5 to 12.5)
0 0
3.0 (0 to 6) 3.1 (0 to 5.5)
3 3
1 1
1 1
0 0
NP NP
NP
NP
NP
9
5
5
0
NP
NP
NP
NP
NP
NP NP NP NP
NP NP 0 NP
2.65 (1 to 9) NP NP 2.2 1.0
15 17 11 22
0 0
C
3 2
8
D
2 3
5
B
C
D
0 9
3 1
0 0
P Value NP NP NP NP
NP 8 10 9
5 2 2 1
1 0 0 1
NP NP
