The American Journal of Sports Medicine http://ajs.sagepub.com/
Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction Bertrand Sonnery-Cottet, Stefan Mogos, Mathieu Thaunat, Pooler Archbold, Jean-Marie Fayard, Benjamin Freychet, Julien Clechet and Pierre Chambat Am J Sports Med 2014 42: 1873 originally published online May 28, 2014 DOI: 10.1177/0363546514534938 The online version of this article can be found at: http://ajs.sagepub.com/content/42/8/1873
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Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction Bertrand Sonnery-Cottet,*y MD, Stefan Mogos,y MD, Mathieu Thaunat,y MD, Pooler Archbold,z MD, Jean-Marie Fayard,y MD, Benjamin Freychet,y MD, Julien Clechet,y MD, and Pierre Chambat,y MD Investigation performed at the Centre Orthope´dique Santy and Hoˆpital Prive´ Jean Mermoz, Lyon, France Background: Physicians should consider an increased posterior tibial slope (PTS) as a risk factor for graft failure when proposing anterior cruciate ligament (ACL) re-revision. Purpose: To describe the surgical technique of combined ACL revision and proximal tibial anterior closing wedge osteotomy and to evaluate its clinical outcome in cases of recurrent graft failure with associated increased tibial slope. Study Design: Case series; Level of evidence, 4. Methods: Between 2008 and 2010, 5 combined ACL re-revisions with proximal tibial anterior closing wedge osteotomy were retrospectively evaluated after a mean 31.6 months’ follow-up (range, 23-45 months). All patients reported subjective knee instability preoperatively and demonstrated increased laxity on physical examination. Intrinsic risk factors for graft failure (excessive tibial slope) were identified in all cases. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale. Results: The mean Lysholm score was 46.2 preoperatively (range, 26-69) and 87.8 (range, 60-100) postoperatively. The mean IKDC subjective score was 39.5 (range, 21.8-64.4) before surgery and 79.1 (range, 48.3-98.9) at the last follow-up. The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last follow-up. The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The mean differential anterior laxity was 10.4 mm (range, 8-14 mm), and this significantly decreased to 2.8 mm (range, 2-4 mm) at the last followup. Using the Kellgren-Lawrence classification to evaluate the presence of arthritis, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3. Conclusion: Combined ACL re-revision with proximal tibial anterior closing wedge osteotomy restores knee stability and function with satisfactory clinical outcomes in patients who experience recurrent ACL ruptures with an associated increased PTS. Keywords: ACL; anterior cruciate ligament; ACL revision; intrinsic risk factors; proximal tibial anterior closing wedge osteotomy An increasing incidence of anterior cruciate ligament (ACL) reconstructions across the world is reported.15,27 As a result of failed primary surgeries,18 there is an increasing number of ACL revisions.1,7,11,13,23,26,31 Despite a relatively high failure rate of revision ACL reconstructions, additional
reconstructive procedures are not commonly performed. This is for multiple reasons including decreased patient activity and expectations and concerns of undergoing a further surgical procedure after 2 previous failed occasions. It is therefore critical to identify and address the factors that may have contributed to graft failure. Excluding technical mistakes, including poor tunnel placement, numerous factors have been implicated to increase the risk of failure of ACL reconstruction. These factors are classified as extrinsic or intrinsic. Although strategies have been developed to optimize extrinsic factors (eg, physical conditioning, proprioception),18 intrinsic factors such as an increased posterior tibial slope (PTS) or a narrow intercondylar notch are not routinely addressed during ACL revision surgery.35-37 As we believe that these factors can be identified as the potential cause for failure of a previous ACL revision, we performed combined ACL revision with proximal tibial
*Address correspondence to Bertrand Sonnery-Cottet, MD, Centre Orthope´dique Santy, 24 Avenue Paul Santy, 69008 Lyon, France (e-mail: [email protected]). y Centre Orthope´dique Santy and Hoˆpital Prive´ Jean Mermoz, Lyon, France. z Musgrave Park Hospital, Belfast, Ireland. One or more of the authors has declared the following potential conflict of interest or source of funding: B.S.-C., M.T., and J.-M.F. are paid consultants for, receive research support from, and have made presentations for Arthrex. The American Journal of Sports Medicine, Vol. 42, No. 8 DOI: 10.1177/0363546514534938 Ó 2014 The Author(s)
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anterior closing wedge osteotomy in re-revision ACL reconstruction with an increased tibial slope, after excluding other common causes of ACL failure. The purpose of this study was to describe the surgical technique and to evaluate its early clinical outcome.
MATERIALS AND METHODS Between 2008 and 2010, there were 5 ACL re-revisions with combined proximal tibial anterior closing wedge osteotomy performed at our institution. All patients had undergone at least 2 previous ACL reconstructions and were identified as suffering a new ACL failure. Trauma was the cause of failure in all cases. All had the typical symptoms and signs of an ACL rupture, which was associated with a pathological PTS (12° according to the technique of Julliard et al22). The clinical evaluation showed an ACL-deficient knee, with positive Lachman and pivot-shift test results, confirmed by magnetic resonance imaging. The exclusion criteria for this study were first or second ACL failure, identified cause of graft failure such as surgical technical errors or missed posterolateral laxity, normal tibial slope, multiligamentous knee injuries, and the presence of radiological signs of arthritis on plain radiographs of the knee according to the Kellgren-Lawrence classification.24 All patients were reviewed, and their clinical data were retrospectively analyzed. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale. Side-to-side differential anterior laxity was measured in all patients using the Telos stress device (Telos GmbH, Marburg, Germany) with 150 N at 20° of knee flexion. Institutional review board approval has been obtained for this study.
Radiological Assessment All patients underwent anteroposterior, lateral weightbearing, and Schuss views (posteroanterior weightbearing in 20°-30° of flexion) of the knee. The assessment was completed with a true lateral view of the knee under fluoroscopic control to ensure that the femoral condyles were superimposed. This confirmation was necessary because for measurement of the tibial slope, the distance between the posterior edges of the condyles on the lateral view should be \5 mm. The functional tibial slope as described by Julliard et al22 was used to determine the PTS, which is the angle between the tangent to the medial tibial plateau and the lateral mechanical axis of the leg (Figure 1). We considered this method to be the most suitable, as other techniques do not use the full length of the tibia nor relate to its mechanical axis. The Kellgren-Lawrence classification was used to evaluate the presence of radiological signs of arthritis.24
Surgical Technique Surgery was performed with the patient under general anesthesia with a femoral nerve block. The patient was
Figure 1. Radiograph showing the method of measuring the posterior tibial slope as the angle formed by the tangent to the medial tibial plateau and perpendicular to the lateral mechanical axis through the middle of the medial tibial plateau and center of the talus. Patient 4: (A, B) Preoperative asymmetric tibial slope. (C) Postoperative corrected tibial slope.
placed in the supine position on the operating table with a tourniquet placed high on the thigh. A lateral post at the level of the tourniquet maintained the leg position in the frontal plane. A distal support placed on the table kept the knee at 90° of flexion, allowing full range of motion when desired. After arthroscopic exploration, notchplasty was performed when indicated because of a narrow notch (3 patients). Tunnel preparation for ACL reconstruction was performed using an outside-in 2-incision technique for femoral tunnel placement as previously described.12 A specific femoral drill guide was positioned under arthroscopic control through the anteromedial portal. One arm of the guide was introduced into the knee, passing between the posterior cruciate ligament and the medial wall of the lateral condyle. With the knee flexed at 90°, the tip of the arm was positioned at the back wall of the lateral condyle so that the guide wire was placed at the center of the native femoral ACL footprint. The external arm of the femoral guide lay on the lateral aspect of the lower part of the thigh. A lateral 2-cm incision was made, and the drill guide was introduced to contact the lateral cortex of the femur. A guide wire was then driven across the lateral condyle to emerge at the center of the femoral ACL footprint. Pin position was confirmed arthroscopically by direct visualization, and the femoral tunnel was then drilled from outside in, irrespective of the position of the previous tunnel. It was not necessary to perform the surgery in 2 stages in any patient. In the majority of cases (4/5), the patellar tendon and hamstring tendon had been previously
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Figure 2. Surgical technique of proximal tibial anterior closing wedge osteotomy. (A) Detachment of the anterior tibial tubercle. (B) Placement of the K-wires. (C) Anterior bony segment resection. (D, E) An anterior bony segment is resected to obtain the desired surgical correction. (F) Fixation of the osteotomy.
harvested for the first and second reconstructions. In these cases, we harvested the ipsilateral quadriceps tendon for the third reconstruction. This was the graft of choice, as the quadriceps graft with a bone plug filled the bony defect. The third step of the surgical procedure was the osteotomy (Figure 2). An anterior longitudinal incision was centered on the anterior tibial tubercle. The tibial tubercle was detached from the intended tibial osteotomy site as a 6-cm bone block. Under fluoroscopic control, 2 K-wires were inserted obliquely, posteriorly, and proximally to mark the osteotomy site, starting about 4 to 5 cm distal to the joint line and aiming at the tibial insertion site of the posterior cruciate ligament. Keeping an intact posterior bony bridge is critical to protect the popliteal structures and limits the risk of secondary displacement or pseudarthrosis. An anterior bony segment was resected to obtain the desired surgical correction. The aim was to obtain a PTS of between 8° and 10°. The anterior closing wedge osteotomy was fixed with 2 staples and positioned medially and laterally with respect to the tibial tubercle. The anterior tibial tubercle was repositioned by translating it distally with an amount equal to the thickness of the removed bony fragment, and it was fixed with 2 anteroposterior cortical screws: one above and the other below the osteotomy site (Figure 3) (see Video Supplement, available online). Two patients in this series (patients 2 and 5) had previously undergone lateral tenodesis during their previous
reconstructions. In a further 2 patients (patients 3 and 4), we performed lateral tenodesis during their last ACL revision. Tenodesis consisted of a 12 3 75–mm strip of the iliotibial band remaining that was attached to the Gerdy tubercle. An isometric point in the region of the Krackow point was determined with a caliper. The iliotibial band strip was twisted by 180° to enhance its isometry. Then, the tenodesis was fixed using an interference screw within a transverse tunnel drilled at the isometric point through the lateral femoral condyle.4 The ACL graft was then advanced from proximal to distal and was fixed at 20° of flexion by press fit at the level of the femoral tunnel and with the use of a bioabsorbable interference screw at the tibial tunnel.
Postoperative Rehabilitation Progressive nonaggressive rehabilitation was initiated immediately postoperatively. During the first 45 days postoperatively, weightbearing was not allowed. The patient was immobilized in a postoperative knee brace locked in extension for 6 weeks. Immediately after surgery, passive and active extension exercises were permitted as tolerated by the patient. Reduction of knee swelling, regaining quadriceps control, and recovery of range of motion were the main objectives of this period. Range of motion exercises aimed at obtaining full extension, avoiding recurvatum
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Figure 3. Example of anterior closing wedge tibial osteotomy in patient 4. (A-C) Intraoperative view and fluoroscopic control of the placement of K-wires after detachment of the anterior tibial tubercle. (D, E) Intraoperative view and fluoroscopic control of anterior bony segment resection. (F) Final view of anterior closing wedge tibial osteotomy after the fixation with staples. even if present on the contralateral side, and increasing flexion at 3 and 6 weeks postoperatively. Progressive weightbearing was started after radiographs at 45 days postoperatively confirmed bony consolidation, with the aim of obtaining full weightbearing at 90 days postoperatively. A gradual return to sports activities was allowed starting at 5 months for nonpivoting sports activities, at 9 months for pivoting noncontact sports activities, and at 1 year for pivoting contact sports activities.
Subjective Knee Evaluation The mean IKDC subjective score was 39.5 (range, 21.864.4) before surgery and 79.1 (range, 48.3-98.9) at the last postoperative follow-up (P = .004). The mean Lysholm score was 46.2 (range, 26-69) preoperatively and 87.8 (range, 60-100) postoperatively at the last follow-up (P = .0008).
Objective Evaluation Statistical Analysis Statistical analysis was performed using SPSS (SPSS Inc, Chicago, Illinois, USA). The paired Student t test was used to compare preoperative and postoperative data. The level of significance was set at P = .05.
RESULTS There were 4 men and 1 woman in our series. The mean follow-up was 31.6 months (range, 23-45 months). The mean patient age at surgery was 24 years (range, 16-40 years). The demographics and characteristics of the 5 patients are presented in Table 1. No complications were noted, and all osteotomies were radiologically united at 3 months. All results are presented in Table 2.
Posterior Tibial Slope The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The preoperative contralateral tibial slope was symmetrical except for patient 4.
Preoperatively, 3 patients were graded C and 2 patients graded D on the IKDC objective score. At the last follow-up, 1 patient was rated A and 4 patients rated B. The mean side-to-side differential anterior laxity with the Telos device was 10.4 mm (range, 8-14 mm) before surgery and significantly decreased to 2.8 mm (range, 24 mm) at the last follow-up (P = .002). Preoperatively, 1 patient had a grade I, 3 patients had a grade II, and 1 patient had a grade III pivot-shift test result. Postoperatively, 4 patients had a negative pivot shift, and 1 patient had grade I.
Sports Activity Level The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last followup. All but 1 patient returned to the same activity level at the last follow-up. Two patients with tibial slopes of 13° and 14° returned to football at the same level as before suffering a contralateral ACL rupture.
Kellgren-Lawrence Classification Preoperatively, 4 patients were classified as KellgrenLawrence grade 1, and 1 patient received a grade 2.
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TABLE 1 Patient Demographics and Characteristicsa
Sex Age at first ACL reconstruction, y Follow-up, mo First ACL rupture Year Graft type Second ACL rupture Year Graft type Third ACL rupture Year Tibial slope, deg Contralateral slope, deg Anterior tibial osteotomy with ACL reconstruction Date Corrected tibial slope, deg ACL graft at latest surgery Previous lateral tenodesis Lateral tenodesis at latest surgery Previous meniscal procedure Meniscal procedure at latest surgery Kellgren-Lawrence grade Preoperative Postoperative Main sport before latest accident
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Male 40 45
Male 24 36
Female 23 23
Male 16 28
Male 17 26
1990 Patellar tendon
2002 Hamstring tendon
2000 Hamstring tendon
2007 Hamstring tendon
2007 Hamstring tendon
2001 Contralateral patellar tendon
2003 Ipsilateral patellar tendon
2001 Ipsilateral patellar tendon
2008 Ipsilateral patellar tendon
2009 Ipsilateral patellar tendon
2007 13 13
2007 13 13
2008 14 14
2009 14 9
2009 14 14
December 17, 2008 10 Contralateral quadriceps tendon — — —
January 5, 2009 8 Ipsilateral quadriceps tendon Yes — —
—
—
November 6, 2010 10 Ipsilateral quadriceps tendon — Yes Partial medial meniscectomy —
2 3 Skiing (recreational)
May 21, 2010 July 23, 2010 8 10 Contralateral Ipsilateral patellar tendon quadriceps tendon — Yes Yes — Partial lateral Partial lateral meniscectomy meniscectomy Partial lateral Lateral meniscal meniscectomy suture
1 1 1 2 2 1 Competitive Competitive athletics Cycling football (national level) (national level) (recreational)
1 2 Competitive football
a
ACL, anterior cruciate ligament.
Postoperatively, at the last follow-up, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3.
DISCUSSION The principle of combined ACL reconstruction and proximal anterior tibial closing wedge osteotomy in patients with a recurrent ACL rupture associated with a pathological PTS has been mentioned in the literature, but no clinical outcome of surgical patients has yet been published. Our results are at least equal to those reported in other studies of ACL revision surgery.3,7,10,11,17,23,26,33 This technique results in good knee function and stability and a predictable return to sports activities without significant complications. None of the patients sustained a further injury to the operated knee during the follow-up period. However, similar to other published studies published on ACL revision, the functional results remain less favorable than those obtained with primary ACL reconstruction.17,28,33,42 Revision of the ACL is a complex surgical procedure that may present numerous technical difficulties. The
presence of cartilage and meniscal injuries is a likely cause of poorer clinical outcomes as compared with primary ACL reconstruction.29,38 Graft choice, previous tunnel malpositioning, bony defects, and subsequent problems that cause inadequate graft fixation represent other major concerns. These factors are more evident when performing ACL rerevision. The indication for revision depends on the patient’s sport and professional requirements. Instability in daily activities of living is a strong argument for revision. However, several series have reported that results after revision of ACL reconstruction are worse than those obtained after primary reconstruction,21,23,32,39,43 with only 54% of the patients returning to their previous level of activity.39 Surgical revision of a failed ACL reconstruction requires thorough preoperative planning and evaluation of the factors that have caused the failure. The most common are considered to be an error in surgical technique (nonanatomic position of the graft) or an unrecognized concomitant ligament injury, particularly posterolateral rotatory instability.41 The determination of these factors must be included in a carefully constructed preoperative
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TABLE 2 Series Resultsa PreoperativePostoperativeP Value Mean posterior tibial slope, deg Mean IKDC subjective score IKDC objective score, no. of patients A B C D Mean Lysholm score Mean anterior laxity, mm Pivot-shift test result, no. of patients 0 I II III Mean Tegner activity score Kellgren-Lawrence grade, no. of patients 1 2 3
13.6 39.5
9.2 79.1
.0005 .004
0 0 3 2 46.2 10.4
1 4 0 0 87.8 2.8
.0008 .002
0 1 3 1 7.4
4 1 0 0 7.2
4 1 0
1 3 1
a
IKDC, International Knee Documentation Committee.
evaluation. However, the role of intrinsic factors (PTS and intercondylar notch) in the repeat failure of ACL reconstruction has not been highlighted in the literature. This is despite it being demonstrated that the risk of ACL injuries is increased by extrinsic and intrinsic factors. Strategies developed to optimize extrinsic factors have only had a minimal effect in decreasing the overall rates of ACL injuries. Also, PTS and the size of the notch are recognized as playing important roles in knee kinematics, joint stability, and pressure distribution. Despite continued debate on the relationship between an increased PTS and an ACL injury,§ it has been recently demonstrated that both factors (PTS and the size of the notch) play a significant role in increasing the risk of ACL injuries.36 This finding is in accordance with the findings of Simon et al.35 An increased PTS has been associated with increased anterior tibial translation,5,6,9 potentially leading to increased strains in the ACL and a greater risk of ACL injuries.2,6,9,19 Dejour and Bonnin5 showed that in both ACL-intact and ACLdeficient knees, there was an increase of 6 mm in anterior tibial translation for every 10° of increased PTS. The magnitude of the displacement was greater in the presence of ACL insufficiency. In a recent article, Webb et al,40 in a prospective longitudinal study over 15 years, enrolled 200 consecutive patients with an isolated ACL rupture. The PTS was measured to analyze the association between an increased PTS and the incidence of further ACL injuries. The mean PTS
§
References 2, 5, 6, 8, 9, 14, 16, 19, 20, 25, 30, 34, 37.
of those with a further ACL injury was 9.9°, compared with 8.5° for those with no further injury. The mean PTS for those with both an ACL graft and contralateral ACL rupture was 12.9°. The odds of further ACL injuries after reconstruction were increased by a factor of 5, to an incidence of 59%, in those with a PTS of 12°. In our series, 2 patients with tibial slopes of 13° and 14° returned to football at the same level as before suffering a contralateral ACL rupture. We did not encounter specific complications with this technique. Proximal anterior tibial closing wedge osteotomy is a technically demanding procedure, associated with significant risks and potential complications. The main risk of this surgical procedure is damage of the neurovascular popliteal structures. Moreover, this procedure increases the operative time and the postoperative rehabilitation period and has many potential specific complications (pseudarthrosis, anterior tibial tubercule migration, stiffness, etc). Therefore, rigorous preoperative planning, an accurate surgical technique, and careful postoperative follow-up are necessary to optimize the clinical outcome. For this reason, we only perform this combined procedure in patients with a highly pathological PTS who experience a third ACL rupture not related to a technical error or missed posterolateral laxity. This suggests that for these patients, the high PTS identified is an important risk factor for graft ruptures. No patient in our series required autologous bone grafting for excessive tibial tunnel enlargement, as previously reported by Wegrzyn et al.41 In their series, they also reported a case of simultaneous repeat ACL reconstruction and valgus high tibial osteotomy (HTO). The indication for simultaneous valgus HTO and ACL reconstruction is not primarily dependent on varus malalignment but on symptomatic unicompartmental degeneration. We did not encounter a case that required both valgus HTO and anterior closing wedge osteotomy, but these 2 procedures could be combined by removing an anterolateral wedge. The potential weakness of this study is that it is a retrospective case series with a limited follow-up and a small number of patients. As with most of the studies already published on ACL revision, the functional results remain less favorable than those obtained with primary ACL reconstruction.17,28,33,42 Yet, a direct comparison is difficult as the duration of the follow-up differs, and there is a possibility that our results will deteriorate over time. Moreover, in the absence of a control group, it is not possible to know whether anterior closing wedge osteotomy prevents graft failure in this population or even if anterior closing wedge osteotomy is sufficient to address this pathological abnormality. Hence, osteotomy may be sufficient in that ACL reconstruction may not be necessary in these patients. A larger number of patients and a longer follow-up period may be needed to better evaluate the results of this procedure and to know if it can prevent graft ruptures. Therefore, the clinical results of this series should be interpreted with caution. This procedure must be considered as a salvage procedure with limited expectations of restoring stability in daily living and recreational sports activities.
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CONCLUSION Combined ACL revision reconstruction with proximal anterior tibial closing wedge osteotomy should be considered in patients who require re-revision of ACL reconstruction when associated with a highly pathological PTS. Preliminary outcomes of this short case series showed promising results, with a high proportion of patients who were able to return to the same preinjury level of activity. A longer follow-up and a larger series are needed to confirm these preliminary results.
A Video Supplement for this article is available in the online version or at http://ajsm.sagepub.com/supplemental.
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15. Granan LP, Bahr R, Steindal K, Furnes O, Engebretsen L. Development of a national cruciate ligament surgery registry: the Norwegian National Knee Ligament Registry. Am J Sports Med. 2008;36(2):308315. 16. Graveleau N, Chambat P. Les ruptures bilate´rales du ligament croise´ ante´rieur. In: Le Genou du Sportif. Vol 10. Journe´e Lyonnaises de Chirurgie du Genou. Paris: Sauramps Me´dical; 2002:335-338. 17. Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year followup. Arthroscopy. 2005;21(4):418-423. 18. Hart JM, Turman KA, Diduch DR, Hart JA, Miller MD. Quadriceps muscle activation and radiographic osteoarthritis following ACL revision. Knee Surg Sports Traumatol Arthrosc. 2011;19(4):634640. 19. Hohmann E, Bryant A, Reaburn P, Tetsworth K. Is there a correlation between posterior tibial slope and non-contact anterior cruciate ligament injuries? Knee Surg Sports Traumatol Arthrosc. 2011;19(Suppl 1):S109-S114. 20. Hudek R, Fuchs B, Regenfelder F, Koch PP. Is noncontact ACL injury associated with the posterior tibial and meniscal slope? Clin Orthop Relat Res. 2011;469(8):2377-2384. 21. Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD. Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res. 1996;325:100-109. 22. Julliard R, Genin P, Weil G, Palmkrantz P. [The median functional slope of the tibia]. Rev Chir Orthop Reparatrice Appar Mot. 1993;79(8):625-634. 23. Kamath GV, Redfern JC, Greis PE, Burks RT. Revision anterior cruciate ligament reconstruction. Am J Sports Med. 2011;39(1):199-217. 24. Kellgren JH, Lawrence JS. Radiological assessment of osteoarthrosis. Ann Rheum Dis. 1957;16(4):494-502. 25. Kostogiannis I, Sward P, Neuman P, Friden T, Roos H. The influence of posterior-inferior tibial slope in ACL injury. Knee Surg Sports Traumatol Arthrosc. 2011;19(4):592-597. 26. Lind M, Lund B, Faunø P, Said S, Miller LL, Christiansen SE. Medium to long-term follow-up after ACL revision. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):166-172. 27. Lind M, Menhert F, Pedersen AB. The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc. 2009;17(2):117-124. 28. Ma Y, Ao YF, Cui GQ, et al. Clinical research on revision after anterior cruciate ligament reconstruction. Zhonghua Wai Ke Za Zhi. 2008;46(9):650-653. 29. McConville OR, Kipnis JM, Richmond JC. The effect of meniscal status on knee stability and function after anterior cruciate ligament reconstruction. Arthroscopy. 1993;9(4):431-439. 30. Meister K, Talley MC, Horodyski MB, Indelicato PA, Hartzel JS, Batts J. Caudal slope of the tibia and its relationship to noncontact injuries to the ACL. Am J Knee Surg. 1998;11(4):217-219. 31. Muneta T, Hara K, Ju YJ, et al. Revision anterior cruciate ligament reconstruction by double-bundle technique using multi-strand semitendinosus tendon. Arthroscopy. 2010;26(6):769-781. 32. Noyes FR, Barber-Westin SD. Revision anterior cruciate ligament surgery: experience from Cincinnati. Clin Orthop Relat Res. 1996;325:116-129. 33. Reinhardt KR, Hammoud S, Bowers AL, Umunna BP, Cordasco FA. Revision ACL reconstruction in skeletally mature athletes younger than 18 years. Clin Orthop Relat Res. 2012;470(3):835-842. 34. Shelburne KB, Kim HJ, Sterett WI, Pandy MG. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res. 2011;29(2):223-231. 35. Simon RA, Everhart JS, Nagaraja HN, Chaudhari AM. A case-control study of anterior cruciate ligament volume, tibial plateau slopes and intercondylar notch dimensions in ACL-injured knees. J Biomech. 2010;43(9):1702-1707. 36. Sonnery-Cottet B, Archbold P, Cucurulo T, et al. The influence of the tibial slope and the size of the intercondylar notch on rupture of the
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anterior cruciate ligament. J Bone Joint Surg Br. 2011;93(11):14751478. Todd MS, Lalliss S, Garcia E, DeBerardino TM, Cameron KL. The relationship between posterior tibial slope and anterior cruciate ligament injuries. Am J Sports Med. 2010;38(1):63-67. Trojani C, Sbihi A, Djian P, et al. Causes for failure of ACL reconstruction and influence of meniscectomies after revision. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):196-201. Uribe JW, Hechtman KS, Zvijac JE, Tjin-A-Tsoi EW. Revision anterior cruciate ligament surgery: experience from Miami. Clin Orthop Relat Res. 1996;325:91-99. Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP. Posterior tibial slope and further anterior cruciate ligament injuries in the
anterior cruciate ligament-reconstructed patient. Am J Sports Med. 2013;41(12):2800-2804. 41. Wegrzyn J, Chouteau J, Philippot R, Fessy MH, Moyen B. Repeat revision of anterior cruciate ligament reconstruction: a retrospective review of management and outcome of 10 patients with an average 3-year follow-up. Am J Sports Med. 2009;37(4):776785. 42. Weiler A, Schmeling A, Sto¨hr I, Ka¨a¨b MJ, Wagner M. Primary versus single-stage revision anterior cruciate ligament reconstruction using autologous hamstring tendon grafts: a prospective matched-group analysis. Am J Sports Med. 2007;35(10):1643-1652. 43. Wirth CJ, Kohn D. Revision anterior cruciate ligament surgery: experience from Germany. Clin Orthop Relat Res. 1996;325:110-115.
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Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction Bertrand Sonnery-Cottet, Stefan Mogos, Mathieu Thaunat, Pooler Archbold, Jean-Marie Fayard, Benjamin Freychet, Julien Clechet and Pierre Chambat Am J Sports Med 2014 42: 1873 originally published online May 28, 2014 DOI: 10.1177/0363546514534938 The online version of this article can be found at: http://ajs.sagepub.com/content/42/8/1873
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Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction Bertrand Sonnery-Cottet,*y MD, Stefan Mogos,y MD, Mathieu Thaunat,y MD, Pooler Archbold,z MD, Jean-Marie Fayard,y MD, Benjamin Freychet,y MD, Julien Clechet,y MD, and Pierre Chambat,y MD Investigation performed at the Centre Orthope´dique Santy and Hoˆpital Prive´ Jean Mermoz, Lyon, France Background: Physicians should consider an increased posterior tibial slope (PTS) as a risk factor for graft failure when proposing anterior cruciate ligament (ACL) re-revision. Purpose: To describe the surgical technique of combined ACL revision and proximal tibial anterior closing wedge osteotomy and to evaluate its clinical outcome in cases of recurrent graft failure with associated increased tibial slope. Study Design: Case series; Level of evidence, 4. Methods: Between 2008 and 2010, 5 combined ACL re-revisions with proximal tibial anterior closing wedge osteotomy were retrospectively evaluated after a mean 31.6 months’ follow-up (range, 23-45 months). All patients reported subjective knee instability preoperatively and demonstrated increased laxity on physical examination. Intrinsic risk factors for graft failure (excessive tibial slope) were identified in all cases. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale. Results: The mean Lysholm score was 46.2 preoperatively (range, 26-69) and 87.8 (range, 60-100) postoperatively. The mean IKDC subjective score was 39.5 (range, 21.8-64.4) before surgery and 79.1 (range, 48.3-98.9) at the last follow-up. The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last follow-up. The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The mean differential anterior laxity was 10.4 mm (range, 8-14 mm), and this significantly decreased to 2.8 mm (range, 2-4 mm) at the last followup. Using the Kellgren-Lawrence classification to evaluate the presence of arthritis, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3. Conclusion: Combined ACL re-revision with proximal tibial anterior closing wedge osteotomy restores knee stability and function with satisfactory clinical outcomes in patients who experience recurrent ACL ruptures with an associated increased PTS. Keywords: ACL; anterior cruciate ligament; ACL revision; intrinsic risk factors; proximal tibial anterior closing wedge osteotomy An increasing incidence of anterior cruciate ligament (ACL) reconstructions across the world is reported.15,27 As a result of failed primary surgeries,18 there is an increasing number of ACL revisions.1,7,11,13,23,26,31 Despite a relatively high failure rate of revision ACL reconstructions, additional
reconstructive procedures are not commonly performed. This is for multiple reasons including decreased patient activity and expectations and concerns of undergoing a further surgical procedure after 2 previous failed occasions. It is therefore critical to identify and address the factors that may have contributed to graft failure. Excluding technical mistakes, including poor tunnel placement, numerous factors have been implicated to increase the risk of failure of ACL reconstruction. These factors are classified as extrinsic or intrinsic. Although strategies have been developed to optimize extrinsic factors (eg, physical conditioning, proprioception),18 intrinsic factors such as an increased posterior tibial slope (PTS) or a narrow intercondylar notch are not routinely addressed during ACL revision surgery.35-37 As we believe that these factors can be identified as the potential cause for failure of a previous ACL revision, we performed combined ACL revision with proximal tibial
*Address correspondence to Bertrand Sonnery-Cottet, MD, Centre Orthope´dique Santy, 24 Avenue Paul Santy, 69008 Lyon, France (e-mail: [email protected]). y Centre Orthope´dique Santy and Hoˆpital Prive´ Jean Mermoz, Lyon, France. z Musgrave Park Hospital, Belfast, Ireland. One or more of the authors has declared the following potential conflict of interest or source of funding: B.S.-C., M.T., and J.-M.F. are paid consultants for, receive research support from, and have made presentations for Arthrex. The American Journal of Sports Medicine, Vol. 42, No. 8 DOI: 10.1177/0363546514534938 Ó 2014 The Author(s)
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anterior closing wedge osteotomy in re-revision ACL reconstruction with an increased tibial slope, after excluding other common causes of ACL failure. The purpose of this study was to describe the surgical technique and to evaluate its early clinical outcome.
MATERIALS AND METHODS Between 2008 and 2010, there were 5 ACL re-revisions with combined proximal tibial anterior closing wedge osteotomy performed at our institution. All patients had undergone at least 2 previous ACL reconstructions and were identified as suffering a new ACL failure. Trauma was the cause of failure in all cases. All had the typical symptoms and signs of an ACL rupture, which was associated with a pathological PTS (12° according to the technique of Julliard et al22). The clinical evaluation showed an ACL-deficient knee, with positive Lachman and pivot-shift test results, confirmed by magnetic resonance imaging. The exclusion criteria for this study were first or second ACL failure, identified cause of graft failure such as surgical technical errors or missed posterolateral laxity, normal tibial slope, multiligamentous knee injuries, and the presence of radiological signs of arthritis on plain radiographs of the knee according to the Kellgren-Lawrence classification.24 All patients were reviewed, and their clinical data were retrospectively analyzed. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale. Side-to-side differential anterior laxity was measured in all patients using the Telos stress device (Telos GmbH, Marburg, Germany) with 150 N at 20° of knee flexion. Institutional review board approval has been obtained for this study.
Radiological Assessment All patients underwent anteroposterior, lateral weightbearing, and Schuss views (posteroanterior weightbearing in 20°-30° of flexion) of the knee. The assessment was completed with a true lateral view of the knee under fluoroscopic control to ensure that the femoral condyles were superimposed. This confirmation was necessary because for measurement of the tibial slope, the distance between the posterior edges of the condyles on the lateral view should be \5 mm. The functional tibial slope as described by Julliard et al22 was used to determine the PTS, which is the angle between the tangent to the medial tibial plateau and the lateral mechanical axis of the leg (Figure 1). We considered this method to be the most suitable, as other techniques do not use the full length of the tibia nor relate to its mechanical axis. The Kellgren-Lawrence classification was used to evaluate the presence of radiological signs of arthritis.24
Surgical Technique Surgery was performed with the patient under general anesthesia with a femoral nerve block. The patient was
Figure 1. Radiograph showing the method of measuring the posterior tibial slope as the angle formed by the tangent to the medial tibial plateau and perpendicular to the lateral mechanical axis through the middle of the medial tibial plateau and center of the talus. Patient 4: (A, B) Preoperative asymmetric tibial slope. (C) Postoperative corrected tibial slope.
placed in the supine position on the operating table with a tourniquet placed high on the thigh. A lateral post at the level of the tourniquet maintained the leg position in the frontal plane. A distal support placed on the table kept the knee at 90° of flexion, allowing full range of motion when desired. After arthroscopic exploration, notchplasty was performed when indicated because of a narrow notch (3 patients). Tunnel preparation for ACL reconstruction was performed using an outside-in 2-incision technique for femoral tunnel placement as previously described.12 A specific femoral drill guide was positioned under arthroscopic control through the anteromedial portal. One arm of the guide was introduced into the knee, passing between the posterior cruciate ligament and the medial wall of the lateral condyle. With the knee flexed at 90°, the tip of the arm was positioned at the back wall of the lateral condyle so that the guide wire was placed at the center of the native femoral ACL footprint. The external arm of the femoral guide lay on the lateral aspect of the lower part of the thigh. A lateral 2-cm incision was made, and the drill guide was introduced to contact the lateral cortex of the femur. A guide wire was then driven across the lateral condyle to emerge at the center of the femoral ACL footprint. Pin position was confirmed arthroscopically by direct visualization, and the femoral tunnel was then drilled from outside in, irrespective of the position of the previous tunnel. It was not necessary to perform the surgery in 2 stages in any patient. In the majority of cases (4/5), the patellar tendon and hamstring tendon had been previously
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Figure 2. Surgical technique of proximal tibial anterior closing wedge osteotomy. (A) Detachment of the anterior tibial tubercle. (B) Placement of the K-wires. (C) Anterior bony segment resection. (D, E) An anterior bony segment is resected to obtain the desired surgical correction. (F) Fixation of the osteotomy.
harvested for the first and second reconstructions. In these cases, we harvested the ipsilateral quadriceps tendon for the third reconstruction. This was the graft of choice, as the quadriceps graft with a bone plug filled the bony defect. The third step of the surgical procedure was the osteotomy (Figure 2). An anterior longitudinal incision was centered on the anterior tibial tubercle. The tibial tubercle was detached from the intended tibial osteotomy site as a 6-cm bone block. Under fluoroscopic control, 2 K-wires were inserted obliquely, posteriorly, and proximally to mark the osteotomy site, starting about 4 to 5 cm distal to the joint line and aiming at the tibial insertion site of the posterior cruciate ligament. Keeping an intact posterior bony bridge is critical to protect the popliteal structures and limits the risk of secondary displacement or pseudarthrosis. An anterior bony segment was resected to obtain the desired surgical correction. The aim was to obtain a PTS of between 8° and 10°. The anterior closing wedge osteotomy was fixed with 2 staples and positioned medially and laterally with respect to the tibial tubercle. The anterior tibial tubercle was repositioned by translating it distally with an amount equal to the thickness of the removed bony fragment, and it was fixed with 2 anteroposterior cortical screws: one above and the other below the osteotomy site (Figure 3) (see Video Supplement, available online). Two patients in this series (patients 2 and 5) had previously undergone lateral tenodesis during their previous
reconstructions. In a further 2 patients (patients 3 and 4), we performed lateral tenodesis during their last ACL revision. Tenodesis consisted of a 12 3 75–mm strip of the iliotibial band remaining that was attached to the Gerdy tubercle. An isometric point in the region of the Krackow point was determined with a caliper. The iliotibial band strip was twisted by 180° to enhance its isometry. Then, the tenodesis was fixed using an interference screw within a transverse tunnel drilled at the isometric point through the lateral femoral condyle.4 The ACL graft was then advanced from proximal to distal and was fixed at 20° of flexion by press fit at the level of the femoral tunnel and with the use of a bioabsorbable interference screw at the tibial tunnel.
Postoperative Rehabilitation Progressive nonaggressive rehabilitation was initiated immediately postoperatively. During the first 45 days postoperatively, weightbearing was not allowed. The patient was immobilized in a postoperative knee brace locked in extension for 6 weeks. Immediately after surgery, passive and active extension exercises were permitted as tolerated by the patient. Reduction of knee swelling, regaining quadriceps control, and recovery of range of motion were the main objectives of this period. Range of motion exercises aimed at obtaining full extension, avoiding recurvatum
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Figure 3. Example of anterior closing wedge tibial osteotomy in patient 4. (A-C) Intraoperative view and fluoroscopic control of the placement of K-wires after detachment of the anterior tibial tubercle. (D, E) Intraoperative view and fluoroscopic control of anterior bony segment resection. (F) Final view of anterior closing wedge tibial osteotomy after the fixation with staples. even if present on the contralateral side, and increasing flexion at 3 and 6 weeks postoperatively. Progressive weightbearing was started after radiographs at 45 days postoperatively confirmed bony consolidation, with the aim of obtaining full weightbearing at 90 days postoperatively. A gradual return to sports activities was allowed starting at 5 months for nonpivoting sports activities, at 9 months for pivoting noncontact sports activities, and at 1 year for pivoting contact sports activities.
Subjective Knee Evaluation The mean IKDC subjective score was 39.5 (range, 21.864.4) before surgery and 79.1 (range, 48.3-98.9) at the last postoperative follow-up (P = .004). The mean Lysholm score was 46.2 (range, 26-69) preoperatively and 87.8 (range, 60-100) postoperatively at the last follow-up (P = .0008).
Objective Evaluation Statistical Analysis Statistical analysis was performed using SPSS (SPSS Inc, Chicago, Illinois, USA). The paired Student t test was used to compare preoperative and postoperative data. The level of significance was set at P = .05.
RESULTS There were 4 men and 1 woman in our series. The mean follow-up was 31.6 months (range, 23-45 months). The mean patient age at surgery was 24 years (range, 16-40 years). The demographics and characteristics of the 5 patients are presented in Table 1. No complications were noted, and all osteotomies were radiologically united at 3 months. All results are presented in Table 2.
Posterior Tibial Slope The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The preoperative contralateral tibial slope was symmetrical except for patient 4.
Preoperatively, 3 patients were graded C and 2 patients graded D on the IKDC objective score. At the last follow-up, 1 patient was rated A and 4 patients rated B. The mean side-to-side differential anterior laxity with the Telos device was 10.4 mm (range, 8-14 mm) before surgery and significantly decreased to 2.8 mm (range, 24 mm) at the last follow-up (P = .002). Preoperatively, 1 patient had a grade I, 3 patients had a grade II, and 1 patient had a grade III pivot-shift test result. Postoperatively, 4 patients had a negative pivot shift, and 1 patient had grade I.
Sports Activity Level The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last followup. All but 1 patient returned to the same activity level at the last follow-up. Two patients with tibial slopes of 13° and 14° returned to football at the same level as before suffering a contralateral ACL rupture.
Kellgren-Lawrence Classification Preoperatively, 4 patients were classified as KellgrenLawrence grade 1, and 1 patient received a grade 2.
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TABLE 1 Patient Demographics and Characteristicsa
Sex Age at first ACL reconstruction, y Follow-up, mo First ACL rupture Year Graft type Second ACL rupture Year Graft type Third ACL rupture Year Tibial slope, deg Contralateral slope, deg Anterior tibial osteotomy with ACL reconstruction Date Corrected tibial slope, deg ACL graft at latest surgery Previous lateral tenodesis Lateral tenodesis at latest surgery Previous meniscal procedure Meniscal procedure at latest surgery Kellgren-Lawrence grade Preoperative Postoperative Main sport before latest accident
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Male 40 45
Male 24 36
Female 23 23
Male 16 28
Male 17 26
1990 Patellar tendon
2002 Hamstring tendon
2000 Hamstring tendon
2007 Hamstring tendon
2007 Hamstring tendon
2001 Contralateral patellar tendon
2003 Ipsilateral patellar tendon
2001 Ipsilateral patellar tendon
2008 Ipsilateral patellar tendon
2009 Ipsilateral patellar tendon
2007 13 13
2007 13 13
2008 14 14
2009 14 9
2009 14 14
December 17, 2008 10 Contralateral quadriceps tendon — — —
January 5, 2009 8 Ipsilateral quadriceps tendon Yes — —
—
—
November 6, 2010 10 Ipsilateral quadriceps tendon — Yes Partial medial meniscectomy —
2 3 Skiing (recreational)
May 21, 2010 July 23, 2010 8 10 Contralateral Ipsilateral patellar tendon quadriceps tendon — Yes Yes — Partial lateral Partial lateral meniscectomy meniscectomy Partial lateral Lateral meniscal meniscectomy suture
1 1 1 2 2 1 Competitive Competitive athletics Cycling football (national level) (national level) (recreational)
1 2 Competitive football
a
ACL, anterior cruciate ligament.
Postoperatively, at the last follow-up, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3.
DISCUSSION The principle of combined ACL reconstruction and proximal anterior tibial closing wedge osteotomy in patients with a recurrent ACL rupture associated with a pathological PTS has been mentioned in the literature, but no clinical outcome of surgical patients has yet been published. Our results are at least equal to those reported in other studies of ACL revision surgery.3,7,10,11,17,23,26,33 This technique results in good knee function and stability and a predictable return to sports activities without significant complications. None of the patients sustained a further injury to the operated knee during the follow-up period. However, similar to other published studies published on ACL revision, the functional results remain less favorable than those obtained with primary ACL reconstruction.17,28,33,42 Revision of the ACL is a complex surgical procedure that may present numerous technical difficulties. The
presence of cartilage and meniscal injuries is a likely cause of poorer clinical outcomes as compared with primary ACL reconstruction.29,38 Graft choice, previous tunnel malpositioning, bony defects, and subsequent problems that cause inadequate graft fixation represent other major concerns. These factors are more evident when performing ACL rerevision. The indication for revision depends on the patient’s sport and professional requirements. Instability in daily activities of living is a strong argument for revision. However, several series have reported that results after revision of ACL reconstruction are worse than those obtained after primary reconstruction,21,23,32,39,43 with only 54% of the patients returning to their previous level of activity.39 Surgical revision of a failed ACL reconstruction requires thorough preoperative planning and evaluation of the factors that have caused the failure. The most common are considered to be an error in surgical technique (nonanatomic position of the graft) or an unrecognized concomitant ligament injury, particularly posterolateral rotatory instability.41 The determination of these factors must be included in a carefully constructed preoperative
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TABLE 2 Series Resultsa PreoperativePostoperativeP Value Mean posterior tibial slope, deg Mean IKDC subjective score IKDC objective score, no. of patients A B C D Mean Lysholm score Mean anterior laxity, mm Pivot-shift test result, no. of patients 0 I II III Mean Tegner activity score Kellgren-Lawrence grade, no. of patients 1 2 3
13.6 39.5
9.2 79.1
.0005 .004
0 0 3 2 46.2 10.4
1 4 0 0 87.8 2.8
.0008 .002
0 1 3 1 7.4
4 1 0 0 7.2
4 1 0
1 3 1
a
IKDC, International Knee Documentation Committee.
evaluation. However, the role of intrinsic factors (PTS and intercondylar notch) in the repeat failure of ACL reconstruction has not been highlighted in the literature. This is despite it being demonstrated that the risk of ACL injuries is increased by extrinsic and intrinsic factors. Strategies developed to optimize extrinsic factors have only had a minimal effect in decreasing the overall rates of ACL injuries. Also, PTS and the size of the notch are recognized as playing important roles in knee kinematics, joint stability, and pressure distribution. Despite continued debate on the relationship between an increased PTS and an ACL injury,§ it has been recently demonstrated that both factors (PTS and the size of the notch) play a significant role in increasing the risk of ACL injuries.36 This finding is in accordance with the findings of Simon et al.35 An increased PTS has been associated with increased anterior tibial translation,5,6,9 potentially leading to increased strains in the ACL and a greater risk of ACL injuries.2,6,9,19 Dejour and Bonnin5 showed that in both ACL-intact and ACLdeficient knees, there was an increase of 6 mm in anterior tibial translation for every 10° of increased PTS. The magnitude of the displacement was greater in the presence of ACL insufficiency. In a recent article, Webb et al,40 in a prospective longitudinal study over 15 years, enrolled 200 consecutive patients with an isolated ACL rupture. The PTS was measured to analyze the association between an increased PTS and the incidence of further ACL injuries. The mean PTS
§
References 2, 5, 6, 8, 9, 14, 16, 19, 20, 25, 30, 34, 37.
of those with a further ACL injury was 9.9°, compared with 8.5° for those with no further injury. The mean PTS for those with both an ACL graft and contralateral ACL rupture was 12.9°. The odds of further ACL injuries after reconstruction were increased by a factor of 5, to an incidence of 59%, in those with a PTS of 12°. In our series, 2 patients with tibial slopes of 13° and 14° returned to football at the same level as before suffering a contralateral ACL rupture. We did not encounter specific complications with this technique. Proximal anterior tibial closing wedge osteotomy is a technically demanding procedure, associated with significant risks and potential complications. The main risk of this surgical procedure is damage of the neurovascular popliteal structures. Moreover, this procedure increases the operative time and the postoperative rehabilitation period and has many potential specific complications (pseudarthrosis, anterior tibial tubercule migration, stiffness, etc). Therefore, rigorous preoperative planning, an accurate surgical technique, and careful postoperative follow-up are necessary to optimize the clinical outcome. For this reason, we only perform this combined procedure in patients with a highly pathological PTS who experience a third ACL rupture not related to a technical error or missed posterolateral laxity. This suggests that for these patients, the high PTS identified is an important risk factor for graft ruptures. No patient in our series required autologous bone grafting for excessive tibial tunnel enlargement, as previously reported by Wegrzyn et al.41 In their series, they also reported a case of simultaneous repeat ACL reconstruction and valgus high tibial osteotomy (HTO). The indication for simultaneous valgus HTO and ACL reconstruction is not primarily dependent on varus malalignment but on symptomatic unicompartmental degeneration. We did not encounter a case that required both valgus HTO and anterior closing wedge osteotomy, but these 2 procedures could be combined by removing an anterolateral wedge. The potential weakness of this study is that it is a retrospective case series with a limited follow-up and a small number of patients. As with most of the studies already published on ACL revision, the functional results remain less favorable than those obtained with primary ACL reconstruction.17,28,33,42 Yet, a direct comparison is difficult as the duration of the follow-up differs, and there is a possibility that our results will deteriorate over time. Moreover, in the absence of a control group, it is not possible to know whether anterior closing wedge osteotomy prevents graft failure in this population or even if anterior closing wedge osteotomy is sufficient to address this pathological abnormality. Hence, osteotomy may be sufficient in that ACL reconstruction may not be necessary in these patients. A larger number of patients and a longer follow-up period may be needed to better evaluate the results of this procedure and to know if it can prevent graft ruptures. Therefore, the clinical results of this series should be interpreted with caution. This procedure must be considered as a salvage procedure with limited expectations of restoring stability in daily living and recreational sports activities.
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Vol. 42, No. 8, 2014
Proximal Tibial Anterior Closing Wedge Osteotomy With ACL Reconstruction
CONCLUSION Combined ACL revision reconstruction with proximal anterior tibial closing wedge osteotomy should be considered in patients who require re-revision of ACL reconstruction when associated with a highly pathological PTS. Preliminary outcomes of this short case series showed promising results, with a high proportion of patients who were able to return to the same preinjury level of activity. A longer follow-up and a larger series are needed to confirm these preliminary results.
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