Closing-Wedge Posterior Tibial Slope–Reducing Osteotomy in Complex Revision ACL Reconstruction

Abstract

Background: A posterior tibial slope (PTS) >12° has been shown to correlate with failure of anterior cruciate ligament (ACL) reconstruction (ACLR). PTS-reducing osteotomy has been described to correct the PTS in patients with a deficient ACL, mostly after failure of primary ACLR. Purpose: To report radiologic indices, clinical outcomes, and postoperative complications after PTS-reducing osteotomy performed concurrently with revision ACLR (R-ACLR). Study Design: Case series; Level of evidence, 4. Methods: A review of medical records at 3 institutions was performed of patients who had undergone PTS-reducing osteotomy concurrently with R-ACLR between August 2010 and October 2020. Radiologic parameters recorded included the PTS, patellar height according to the Caton-Deschamps Index (CDI), and anterior tibial translation (ATT). Patient-reported outcomes (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]), reoperations, and complications were evaluated. Results: Included were 23 patients with a mean follow-up of 26.7 months (range, 6-84 months; median, 22.5 months). Statistically significant differences from preoperative to postoperative values were found in PTS (median [range], 14.0° [12°-18°] vs 4.0° [0°-15°], respectively; P < .001), CDI (median, 1.00 vs 1.10, respectively; P = .04) and ATT (median, 8.5 vs 3.6 mm, respectively; P = .001). At the final follow-up, the IKDC score was 52.4 ± 19.2 and the KOOS subscale scores were 81.5 ± 9.5 (Pain), 74 ± 21.6 (Symptoms), 88.5 ± 8 (Activities of Daily Living); 52.5 ± 21.6 (Sport and Recreation), and 48.8 ± 15.8 (Quality of Life). A traumatic ACL graft failure occurred in 2 patients (8.7%). Reoperations were necessary for 6 patients (26.1%) because of symptomatic hardware, and atraumatic recurrent knee instability was diagnosed in 1 patient (4.3%). Conclusion: Tibial slope–reducing osteotomy resulted in a significant decrease of ATT and can be considered in patients with a preoperative PTS ≥12° and ≥1 ACLR failure. In highly complex patients with multiple prior surgeries, the authors found a reasonably low graft failure rate (8.7%) when utilizing PTS-reducing osteotomy. Surgeons must be aware of potential complications in patients with multiple previous failed ACLRs.

Association of Posterior Tibial Slope With Outcomes After Multiligamentous Knee Reconstruction for Knee Dislocation Grades 2 to 4

“…6 More recently, proximal tibial osteotomies have been indicated in patients with a PTS .12°to decrease the risk of ACL graft failure, especially in the revision setting. 3,11,12,37,40,41 In our study of patients who underwent combined ACL and PCL reconstruction, no differences were seen for PROs, Lachman test, ACL graft failure, or ACL revision in patients with a PTS .12°.…”

Evaluation of Anterior Tibial Translation Under Physiological Axial Load After ACL Reconstruction With Lateral Extra-articular Tenodesis

“… 8 In revision ACLR with a high tibial slope, TDO can reduce the SATT. The SATT was reduced from 8.5 to 3.6 mm in the setting of primary and secondary revision ACLR when combined with a TDO 53 and from 11.7 ± 5.2 mm to 4.3 ± 2.5 mm in secondary revision ACLR when combined with a TDO, 10 and a small number of cases demonstrated increased tibial slope and SATT in the primary TDO and ACLR setting. 6 The present study reports an important negative finding—LET did not influence SATT.…”

Anterior Proximal Tibial Screw Hemiepiphysiodesis Decreases Posterior Tibial Slope in Knee Flexion Contracture

“…Biomechanical studies have demonstrated that decreasing PTS by high tibial osteotomy has a protective effect on ACL grafts by reducing the load applied on the graft 28,29 . Clinical implementation of this concept shows promising results [30][31][32] . However, osteotomies are significant procedures with elevated complication rates.…”