Abstract
Anterior cruciate ligament (ACL) tears with known risk factors for anterior cruciate ligament reconstruction (ACLR) graft failure, such as elevated posterior tibial slope ≥12°, require a comprehensive treatment approach. In primary ACLRs, slope-reducing anterior closing-wedge proximal tibial osteotomies are not frequently necessary; however, when slope is severely increased (>18°), they should be considered. This Technical Note describes a single-stage combined primary ACLR, anterior closing-wedge proximal tibial osteotomy, and lateral extra-articular tenodesis in a patient with a chronic ACL tear with increased posterior tibial slope.
Technique Video
In the setting of anterior cruciate ligament (ACL) tears, a patient-specific approach and comprehensive assessment on the basis of known risk factors and concomitant pathology should guide surgical treatment to prevent anterior cruciate ligament reconstruction (ACLR) graft failure. An increasingly recognized risk factor of ACLR failure is an elevated posterior tibial slope (PTS),1,2 described as a PTS of ≥12°.3 Slope-reducing anterior closing wedge slope proximal tibial osteotomies (ACW-PTOs) frequently are indicated in revision ACLR, but few studies have reported on an ACLR with an ACW-PTO in the primary setting.4,5 With concomitant injury pathology, it becomes increasingly important to address altered knee biomechanics in the acute setting, especially with a severe increase in PTS (>18°), to prevent recurrent ACLR graft failure and to restore knee biomechanics. This technique describes a single-stage combined primary ACLR, ACW-PTO, and lateral extra-articular tenodesis (LET) for chronic ACL tear with increased posterior tibial slope.
Surgical Technique
A detailed video of the assessment, ACLR, ACW-PTO, and LET is shown in Video 1. The step-by-step guide and surgical pearls are included in Table 1.6
Table 1.
Step-by-Step Guide and Surgical Pearls for Single-Stage Primary ACLR with Slope-Reducing ACW-PTO and an LET
| Step-by-Step Guide | Pearls |
|---|---|
| An anterior midline incision is made to completely expose the extensor mechanism. | The incision should extend 6 cm proximal to the patella to 6 cm distal to the tibial tubercle |
| Continue dissection medially over the joint line and laterally over the ITB. | To expose the margins of the closing-wedge osteotomy, elevate the lateral periosteum and tissues just above the anterior compartment. This should extend from the lateral aspect of the patellar tendon proximally anterior to the tibiofibular joint. Medially, a 1-cm area of periosteum, starting at the MCL and continuing completely under the patellar tendon. |
| A quadriceps tendon with patellar bone plug autograft is harvested for the ACLR. This site is then closed, and the patellar bone through is later bone grafted using the wedge from the osteotomy. | The graft should be full-thickness 9-mm wide × 9-cm long with a patellar bone plug that is 10 × 20 mm. Take care to not overharvest from the proximal pole of the patella to prevent a stress riser. |
| The LET graft is harvested and fixed with a Q-FIX to reconstitute the ALL tibial anatomic attachment. | An 8-cm long × 1-cm wide strip is taken of the inferior third of the ITB for the LET graft, keeping it attached to Gerdy's tubercle and placing a Q-FIX 1 cm distal to the joint line, midway between Gerdy's tubercle and the anterior margin of the fibular head. |
| Anteromedial and anterolateral parapatellar portals are created and the joint is insufflated. | Assessment of the suprapatellar pouch, lateral and medial gutters, and intra-articular compartments is made. Loose bodies and intercondylar osteophyte are debrided to prevent graft impingement. Within primary ACL tears, medial meniscus ramp tears and lateral meniscus root tears have a reported incidence from 9.0% to 41% and 6.6% to 15%, respectively, and 4.0% to 8.0% in combination.6 Assessment of ramp and roots areas of the medial and lateral menisci should be made before corrective osteotomy. |
| The ACL remnant is identified, debrided, and femoral reconstruction tunnel is created. | A burr hole is created anteromedial and posterolateral bundles of the ACL and a Beath pin is driven anterolaterally. A 10-mm reamer reams to a depth of 25 mm, ensuring a 2-mm back wall is maintained. |
| The medial meniscus ramp tear is identified and repaired. | The MCL can be elevated with a Cobb elevator to improve access and visualization. The margins of the medial meniscus ramp tear are thoroughly rasped. Vertical mattress sutures are placed inferior and superior along the length of the tear, securing the tear. |
| The lateral meniscus root tear is identified and prepped for final repair and fixation. The root attachment is decorticated, and 2 cannulas are drilled for suture shuttling. | Use a Bovie to mark the planned osteotomy wedge to confirm that a lateral meniscus root repair with a transtibial technique would be unaffected by the osteotomy cut. Two suture tapes are placed and shuttled down the transtibial tunnels. |
| The tibial insertion of the ACL is identified. A guide pin is drilled superolaterally and then overreamed with a 10-mm acorn reamer. | The footprint is adjacent to the anterior horn of the lateral meniscus. Ensure the aperture is clear of soft tissue and any residual scarring. |
| Attention is now brought to the slope-reducing ACW-PTO. | Place 2 guide pins are placed perpendicular to the tibial shaft, just above the tibial tubercle. The next 2 pins are placed proximally ensuring the trajectory converges with the other pins on the posterior cortex, confirming with fluoroscopy. Generally, 1 mm equals 1° of slope correction for a supratubercle closing-wedge osteotomy relating to the distance between proximal and distal guide pins. |
| The ACW-PTO cuts are made, and the bone wedge is removed. | A small ACL saw is used medially and laterally. A curette is used to clear cancellous bone posteriorly. This bone can be used for bone grafting of the patella. |
| The ACW-PTO is closed and fixed with 3 large Richard staples. | The knee should be carefully hyperextended to prevent posterior blow out. Two staples should be placed medial and one lateral to the tibial tubercle at the margins of the osteotomy. Final fluoroscopic images should be taken to confirm flush closure. |
| The ACL graft is passed and fixed. The lateral meniscus root is fixed. | The graft is fixed in the femoral tunnel with a 7 × 20-mm titanium interference screw and a post a washer on the tibia. The graft should be taut and fixed in full knee extension. The root should be fixed under direct visualization and with a button proximal to the osteotomy margin. |
| The LET is then fixed at its femoral insertion. | The femoral attachment for the LET is 5 mm posterior and proximal to the lateral epicondyle. A Q-FIX is placed and then the graft is fixed at 20° of knee flexion and neutral rotation. |
| Deep and superficial tissues are closed in layered fashion. | Layered closure prevents hematoma postoperatively. |
ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; ACW-PTO, anterior closing-wedge proximal tibial osteotomy; ALL, anterolateral ligament; ITB, iliotibial band; LET, lateral extra-articular tenodesis; MCL, medial collateral ligament; PTO, proximal tibial osteotomy.
Patient Evaluation, Imaging, and Indications
For patients with suspected ACL tears, assessment should combine clinical examination, radiographic assessment (Fig 1), and diagnostic magnetic resonance imaging scans (Figs 2 and 3) to evaluate known risk factors and concomitant injuries. For patients with gross instability and a significantly increased PTS ≥18° (Fig 1), an ACW-PTO may be indicated as a concomitant procedure in a primary ACLR to reduce the risk of retear.4
Fig 1.
Lateral standing radiographs of the right knee measuring posterior tibial slope (PTS) using the anatomic axis technique. Line are drawn 5 cm distal to the knee joint line and 5 cm proximal to the tibiotalar joint, in between the anterior and posterior tibial cortices. A line is then drawn from their midpoints on the sagittal axis vertically. A horizontal line is made parallel to the lateral tibial plateau and the angle that is created is representative of the PTS. The right PTS measures 21°. Concern for excessive anterior tibial translation and anterior cruciate ligament reconstruction graft overload occurs with elevated slopes of ≥12°. Slope-reducing correction for an anterior closing-wedge proximal tibial osteotomy can be mapped preoperatively, placing the proximal pins of the correction >15 mm distal to the joint line.
Fig 2.
Preoperative magnetic resonance imaging (MRI) of a sagittal view of the right knee. An MRI scan should be used diagnostically to assess for an anterior cruciate ligament (ACL) tear, concomitant ligament, meniscus, and/or osteochondral injury. In this patient, a chronic ACL tear is present (A) and a separation of the medial meniscocapsular junction is indicative of a medial meniscus ramp tear (B).
Fig 3.
Coronal-view (A) and sagittal-view (B) preoperative magnetic resonance imaging (MRI) scan of the right knee. An MRI scan should be used diagnostically to assess for an anterior cruciate ligament (ACL) tear, concomitant ligament, meniscus, and/or osteochondral injury. This patient’s preoperative MRI scan includes increased signal intensity on the posterior lateral tibial plateau indicative of bone bruising commonly associated with pivot shift mechanisms that can result in a lateral meniscus posterior root injury with ACL tears. A ghost sign (B, white arrow) is present at the lateral meniscus root because of the extrusion of its insertion from the joint, indicative of a lateral meniscus posterior root tear.
Anesthesia and Positioning
The patient is placed supine on the operating table and induced under general anesthesia. An examination under anesthesia is performed to confirm the clinical findings. A high-thigh tourniquet is placed on the surgical leg. The surgical leg is placed in an extremity holder (Mizho OSI, Union City, CA) and the patient is administered 2 g of Ancef (cefazolin) for prophylaxis against infection.
Anterior Approach and Osteotomy Site Preparation
An opening incision is made from 6 cm proximal to the patella to 6 cm distal to the tibial tubercle. Dissection is carried down to expose the extensor mechanism (Fig 4). This dissection continues medially over the medial joint line and laterally over the iliotibial band (ITB).
Fig 4.
Right knee anterior midline approach for the anterior cruciate ligament reconstruction (ACLR), slope-reducing anterior closing-wedge proximal tibial osteotomy (ACW-PTO), medial and lateral meniscus repairs, and lateral extra-articular tenodesis (LET). The incision begins 6 cm proximal to the patella and extends 6 cm distal to the tibial tubercle to expose the extensor mechanism (white arrow). The incision is extended lateral to expose the iliotibial band for preparation of the LET and medial to allow for the inside-out medial meniscus ramp repair.
The exposure for the closing-wedge osteotomy is made first to identify structures before fluid extravasation. The lateral periosteum and the tissues just above the anterior compartment are elevated proximally for 1 cm, and this continues between the lateral aspect of the patellar tendon and the anterior proximal tibiofibular joint. Dissection is then performed medially, starting at the medial collateral ligament and continuing to the patellar tendon, proximally elevating a 1-cm layer of periosteum and clearing under the patellar tendon so it can be retracted later in the procedure (Fig 5).
Fig 5.
Right knee anterior midline approach with the patient in the supine position. The exposure for the closing-wedge osteotomy begins first by elevating tissue both medial and lateral. The lateral periosteum above the anterior compartment is elevated proximally for 1 cm and continues between the lateral aspect of the patellar tendon to the anterior proximal tibiofibular joint. Medial dissection is carried further proximally, and a 1-cm area of periosteum, starting at the medial collateral ligament and continuing to the patellar tendon and deep to the patellar tendon (PT) (black arrow) is created to allow for retraction during the osteotomy.
Quadriceps Autograft Harvest and LET Preparation
A full-thickness 9-cm long and 9-mm-wide quadriceps tendon autograft with a 10 × 20-mm patellar bone plug is harvested (Fig 6). A Cobb elevator is then used to remove any adhesions and separate the superficial tissue from the quadriceps tendon. After the harvest, the site is closed with a VICRYL stitch (Ethicon Inc., Raritan, NJ), and the superior pole of the patella is later bone grafted with the wedge portion from the osteotomy.
Fig 6.
Right knee anterior midline approach is shown with the patient in the supine position. For the quadriceps tendon autograft harvest for the anterior cruciate ligament reconstruction, a spinal needle is placed at the proximal pole of the patella (A). A 10 × 20-mm bone block is removed from the patella (B) and a full-thickness 9-mm wide and 9-cm long graft is harvested, leaving the bone block attached. The harvest site (C) can be bone grafted later in the procedure within the patella and the margins of the quadriceps tendon are closed with suture.
Dissection is carried laterally, exposing the ITB, and an 8 × 1-cm strip of the inferior third of the ITB is harvested for the LET, leaving it attached to Gerdy's tubercle according to a previously described technique.7 A Q-FIX anchor (Smith & Nephew, London, England) is placed midway between the anterior aspect of the fibular head and the Gerdy tubercle, 1 cm distal to the joint line at the tibial attachment site of the anterolateral ligament,8 and the LET graft is fixated (Fig 7). The femoral attachment for the anterolateral ligament is identified, 5 mm posterior and proximal to the lateral epicondyle, and a coagulator mark is made for later placement of a Q-FIX.
Fig 7.
Right knee, lateral view, from an extended anterior midline approach with the patient in supine position. The iliotibial band (ITB) is exposed laterally and an 8-cm long × 1-cm wide strip of the inferior third of the ITB is harvested for the anatomic lateral extra-articular tenodesis (LET), keeping its tibial insertion attached to Gerdy's tubercle. A Q-FIX anchor (Smith & Nephew, London, UK) is placed 1 cm distal to the joint line, midway between the anterior aspect of the fibular head and to Gerdy's tubercle. The LET graft is sewn to the tibia to reconstitute the anatomic attachment site of the anterolateral ligament. A retractor is used to isolate under the proximal aspect of the fibular collateral ligament and locate the lateral epicondyle. A coagulator is used to mark 5 mm posterior and proximal at where the LET femoral fixation will later occur.
Arthroscopy and Tunnel Prep
Anteromedial and anterolateral portals are now made, the camera is inserted, and the joint is insufflated with normal saline. Assessment of the suprapatellar pouch, lateral and medial gutters, and intra-articular compartment follows. The ACL tear is identified. For chronic ACL tears, if there is formation of osteophytes present in the intercondylar notch, a notchplasty may be indicated to prevent ACLR graft impingement. Then, a burr hole is placed midway between the anteromedial and posterolateral bundles of the ACL, and a guide pin is driven anterolaterally out of the thigh with the knee maximally flexed using a 7-mm offset over-the-top ACL tibial guide (Arthrex, Naples, FL). This is overreamed with a 10-mm low-profile reamer to a depth of 25 mm, maintaining a 2-mm back wall from the posterior cartilage margin on the lateral femoral condyle. A passing stitch is placed (Fig 8). Attention is now brought to the medial and lateral menisci to assess root and ramp attachment areas; any tears are addressed before ACL tibial tunnel reaming (Figs 9 and 10).
Fig 8.
Right knee arthroscopic view from the anterolateral portal of the anterior cruciate ligament (ACL) tunnel preparation. A burr is used to create a hole midway between the anteromedial and posterolateral bundles of the previously debrided torn ACL. A Beath pin (white arrow) is driven anterolaterally out the thigh at the center of the tunnel aperture (B). A 10-mm low-profile reamer is then used to overream to a depth of 25 mm, maintaining a 2-mm back wall. A passing stitch is then placed to facilitate future ACL reconstruction graft passage (C). (FT, femoral tunnel; LFC, lateral femoral condyle; PCL, posterior cruciate ligament; PCM, posterior cartilage margin.)
Fig 9.
Right knee arthroscopic view from the anterolateral (A) and anteromedial (B and C) portals of the unstable medial meniscus ramp tear (MMRT). The medial collateral ligament (MCL) was previously elevated off the tibia during osteotomy site preparation which increases visualization and access for repair. The arthroscope is inserted through the intercondylar notch via the transnotch view to confirm the meniscocapsular separation of the medial meniscus (MM) (A). A rasp is used on the inferior and superior margins along the length of the tear (B) and 7 inside-out vertical mattress sutures are placed to secure the ramp tear. (MFC, medial femoral condyle; PC, posterior capsule; PHMM, posterior horn of the medial meniscus; PMC, posteromedial capsule; PMTP, posteromedial tibial plateau.)
Fig 10.
Right knee arthroscopic view from the anterolateral portal of the unstable lateral meniscus posterior root tear (LMRT) and repair. The tear is identified and separated from its posteriorly subluxed position using arthroscopic scissors (A). A Bovie is then used to mark on the anteromedial and anterolateral tibial cortices where the planned osteotomy wedge will occur, confirming a transtibial repair technique for the lateral meniscus posterior root will be unaffected by the osteotomy cut. The tibial root attachment is then decorticated, and 2 cannulated pins are drilled from the anterolateral tibia into the decorticated root attachment. A straight FIRSTPASS MINI (Smith & Nephew, London, UK) is used (B) to place 2 ULTRATAPE (purple and black arrows) (Smith & Nephew) vertical mattress sutures into the LMRT which are shuttled down the cannulas (white arrow) (C) and tied to an EndoButton (Smith & Nephew) on the tibial cortex proximal to the osteotomy wedge. (LFC, lateral femoral condyle; LM, lateral meniscus; PLTP, posterolateral tibial plateau.)
The ACL tibial footprint is now identified and outlined adjacent to the anterior horn of the lateral meniscus, and a guide pin is drilled using an ACL tibial guide (Smith & Nephew). This is overreamed with a 10 mm acorn reamer, ensuring the apertures are cleaned for graft shuttling (Fig 11).
Fig 11.
Right knee, arthroscopic view, from the anterolateral portal of the anterior cruciate ligament (ACL) tibial tunnel drilling. The ACL tibial footprint is now identified just adjacent to the anterior insertion of the lateral meniscus. A standard tibial guide (Smith & Nephew, London, UK) is used to drive a guide pin anterolaterally (A). The pin is then overreamed with a 10-mm acorn reamer (B), and a Kocher is used to secure the pin to prevent protrusion into the compartment leading to possible iatrogenic damage of the condylar cartilage. The aperture of the tibial tunnel (TT) is cleaned with a shaver to allow for smooth graft passage (C). (AHLM, anterior horn of the lateral meniscus; MFC, medial femoral condyle.)
Anterior Closing-Wedge Proximal Tibial Osteotomy
Fluoroscopic imaging is now brought in, the foot of the bed is brought up sterilely, and the leg holder is removed. Two guide pins are placed perpendicular to the tibial shaft on each side of the patellar tendon, just above the tibial tubercle. Interoperative fluoroscopy is used to assess the trajectory and position of each pin before progressing to the next pin. An additional 2 pins are placed proximally at a trajectory where the pins converge and meet at the posterior cortex of the planned wedge resection at the other pin pair, and this is again confirmed with fluoroscopy. A general rule of thumb for slope-reducing osteotomies is that 1 mm equals 1° of slope for the distance between the guide pins.9 A small ACL saw blade is then used along the previously delineated margins to cut out the cortical wedge for the osteotomy for the planned slope correction. A curette is used to sufficiently clean the cancellous bone posteriorly, which should be confirmed fluoroscopically. The osteotomy is now carefully closed by hyperextending the surgical extremity, applying a gentle force to the anterior tibia, distal to the wedge, while elevating the heel. Fixation occurs with three large Richard staples, 2 medially and 1 laterally, to secure the closure (Fig 12). A cannula can be used as a placeholder within the ACL tibial tunnel to confirm that there is no collision from the staples with the tunnel. The desired location of the staples is confirmed one final time with fluoroscopy, and an impactor is used to impact them flush to the cortex. A 10-mm reamer is placed up the ACL tibial tunnel by hand to ensure there is no interference within the tunnel that will prevent passage of the ACLR graft. Any adhesions or overlying cancellous bone are removed, and clear apertures are confirmed with the arthroscope before final graft passage.
Fig 12.
Interoperative fluoroscopy of right knee lateral view of slope-reducing anterior closing-wedge proximal tibial osteotomy (ACW-PTO) progression. A 12-mm slope correction was planned preoperatively, and 2 guide pins are placed perpendicular to the tibial shaft, just above the tibial tubercle and 1.5 cm distal to the joint line. Two additional pins are placed proximally, converging at the posterior cortex to create the planned wedge resection, and are confirmed with fluoroscopy (A). A small cruciate ligament saw blade is then used to cut out the cortical wedge for the osteotomy and a curette is used to sufficiently remove the bone posteriorly (B). The osteotomy is now carefully closed down by hyperextending the surgical extremity and placing 3 large Richard staples, 2 medially (white arrows) and one laterally (black arrows), to secure the closure. We noted that the patient’s Lachman test was now 1+ compared with 3+ preoperatively as a result of the slope reduction.
Final Fixation and Closure
The ACL graft is then passed into the femoral tunnel and is fixed with a 7 × 20-mm titanium interference screw in the femur (Smith & Nephew). The ACL graft is now tensioned in full extension and fixed to the tibia with a post and washer. The arthroscope is reinserted into the joint to confirm the ACL graft is taut without impingement (Fig 13).
Fig 13.
Right knee, arthroscopic view, from the anterolateral portal of the anterior cruciate ligament (ACL) femoral fixation and complete reconstruction. A passing suture (A) is used to pass the quadriceps tendon autograft into the femoral tunnel with the bone plug cortical surface facing posteriorly (B). A 7 × 20-mm titanium interference screw (Smith & Nephew) is passed through a cannula, and the ACL reconstruction graft is secured in the femoral tunnel. The graft is properly tensioned and cycled to prevent slack and is then fixed in full extension to the tibia with a post and washer. The arthroscope is reinserted into the joint to confirm the ACL graft is taut without impingement (C).
The LET graft is now fixed to the femur using a Q-FIX anchor with MINITAPE (Smith & Nephew) at the previously marked location with tension, the knee in 20° of flexion, and neutral rotation (Fig 14). The tourniquet is now let down, and the deep and superficial tissues are closed with 0 and 2-0 VICRYL and a MONOCRYL stitch (Ethicon Inc.) for the skin in a layered fashion.
Fig 14.
Right knee, lateral view, from an extended anterior midline approach for femoral fixation of a lateral extra-articular tenodesis (LET) with the patient in supine position. A Q-FIX anchor (Smith & Nephew) with MINITAPE is placed at the previously prepared site 5 mm posterior and 5 mm proximal to the lateral epicondyle. With the knee in 20° of flexion and with the knee in neutral rotation, with tension on the graft, the LET graft is fixed down to the femur. This eliminated the internal rotation of the knee further.
Postoperative Protocol
The patient will be non−weight-bearing on the surgical limb for 8 weeks. Flexion will be limited to 90° for the first 2 weeks and then may increase as tolerated. Hyperextension should be avoided for the first 3 months postoperatively.
Discussion
The goal of a concomitant ACW-PTO and primary ACLR is to protect the graft against excessive loading as it incorporates. A biomechanical study by Bernhardson et al.10 observed that PTS is strongly correlated with the amount of force on an ACLR grafts during axial loading. Flatter tibial slopes, native and corrected, observed significantly less loading of ACL grafts.
Furthermore, it is known that the meniscus functions as a secondary stabilizer to anterior tibial translation and restraint to rotational instability, and deficiency can present a greater risk for ACLR failure. A study by Bernholt et al.11 investigated the effect of increased PTS on concomitant ACL injury pathology and observed incidence of LMRTs increased significantly with elevated PTS. In chronic ACL-deficient knees, MMRTs are likely to exacerbate due to repetitive loading, translational, and rotational forces due to increased laxity.12
In cases in which an extensive injury to the meniscus results in instability, a slope-reducing ACW-PTO can act as both a protective buffer against anterior tibial translation and graft/meniscus repair overloading. A systematic review by Tollefson et al.4 included 16 studies that analyzed slope-reducing proximal tibial osteotomies for ACLR with elevated PTS. They reported slope reducing osteotomies concurrent or before a second-stage ACLR improved patient-reported outcomes, significantly decreased PTS and ATT, and observed lower ACLR failure rates.4 With these biomechanical consequences in mind, it is important to address severe increases in PTS in the acute phase to optimize long-term outcomes. The advantages and disadvantages of this technique are presented in Table 2.
Table 2.
Advantages and Disadvantages of a Single-Stage Primary ACRL With Slope-Reducing ACW-PTO and an LET
| Advantages | Disadvantages |
|---|---|
| Concomitant ACW-PTO and ACLR reduce recovery time compared to a 2-stage procedure. | Larger procedure and more technically demanding for physicians. Risk of tunnel convergence with osteotomy wedge. |
| Quadriceps tendon autograft with a bone block off the patella facilitate bone to bone healing in the femoral ACL tunnel and prevents impingement in the tibial tunnel after osteotomy closure. | Risk of stress riser developing in the patella. Use of autograft may increase incidence of anterior knee pain postoperatively. |
| Use of autografts are cost effective and optimize outcomes when compared with allograft reconstructions. | Risk of morbidity at graft donor sites with larger incision required to access quadriceps tendon autograft. |
| Slope reducing ACW-PTO reduces ATT that protects concomitant medial and lateral meniscus repairs. | Limits weight-bearing status postoperatively with 8 weeks non−weight-bearing for osteotomy site healing. |
ACLR, anterior cruciate ligament reconstruction; ACW-PTO, anterior closing-wedge proximal tibial osteotomy; ATT, anterior tibial translation; LET, lateral extra-articular tenodesis.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: R.F.L. reports consulting or advisory and funding grants from Ossur; consulting or advisory, funding grants, and travel reimbursement from Smith & Nephew; consulting or advisory with Responsive Arthroscopy; funding grants from the Arthroscopy Association of North America and the American Orthopaedic Society for Sports Medicine; speaking and lecture fees from Foundation Medical, LLC, and patent with royalties paid to Ossur. All other authors (E.P.S., L.V.T., D.R.L., M.T.R.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
This is a video technique describing a single-stage primary anterior cruciate ligament reconstruction (ACLR) with slope-reducing anterior closing-wedge proximal tibial osteotomy (ACW-PTO) and a lateral extra-articular tenodesis (LET). The patient is placed in the supine position and examination under anesthesia is performed to confirm clinical findings. An anterior midline incision is made from 6 cm proximal to the patella and 6 cm distal to the tibial tubercle. Dissection is continued medially and laterally over the iliotibial band (ITB) and over the medial joint line. A quadriceps tendon with patellar bone plug autograft is harvested for the ACLR and then site is closed. The LET graft is harvested from the ITB and fixed with a Q-FIX anchor to the tibia. Anteromedial and anterolateral parapatellar portals are made, the anterior cruciate ligament (ACL) remnant is identified, debrided, and the femoral reconstruction tunnel is created. The meniscocapsular separation of the medial meniscus ramp tear is identified and fix with inside-out vertical mattress sutures. Attention is then brought to the lateral meniscus root tear, and the root insertion is decorticated, and 2 cannulas are drilled for suture shuttling, prepping for final fixation. The tibial insertion of the ACL is then identified and guide pin is drilled superolaterally and then overreamed with a 10-mm acorn reamer. The wedge cuts for the ACW-PTO are prepared using a Bovie laterally and medially, and a small ACL saw is used to remove the cortical wedge. The ACW-PTO is closed and fixed with 3 large Richard staples, and a 10-mm low profile reamer is hand reamed to clear the tunnel for graft passage. The lateral root transtibial repair is fixed to the lateral tibial cortex with an EndoButton. The ACLR graft is passed into the femoral tunnel and fixed with a titanium interference screw. The ACLR graft is cycled and fixed in full extension on the tibia with a post and washer. The LET graft is fixed last at the previously marked spot on the femur with the knee in 20° of knee flexion and neutral rotation. Deep and superficial tissues are closed with suture.
References
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Supplementary Materials
This is a video technique describing a single-stage primary anterior cruciate ligament reconstruction (ACLR) with slope-reducing anterior closing-wedge proximal tibial osteotomy (ACW-PTO) and a lateral extra-articular tenodesis (LET). The patient is placed in the supine position and examination under anesthesia is performed to confirm clinical findings. An anterior midline incision is made from 6 cm proximal to the patella and 6 cm distal to the tibial tubercle. Dissection is continued medially and laterally over the iliotibial band (ITB) and over the medial joint line. A quadriceps tendon with patellar bone plug autograft is harvested for the ACLR and then site is closed. The LET graft is harvested from the ITB and fixed with a Q-FIX anchor to the tibia. Anteromedial and anterolateral parapatellar portals are made, the anterior cruciate ligament (ACL) remnant is identified, debrided, and the femoral reconstruction tunnel is created. The meniscocapsular separation of the medial meniscus ramp tear is identified and fix with inside-out vertical mattress sutures. Attention is then brought to the lateral meniscus root tear, and the root insertion is decorticated, and 2 cannulas are drilled for suture shuttling, prepping for final fixation. The tibial insertion of the ACL is then identified and guide pin is drilled superolaterally and then overreamed with a 10-mm acorn reamer. The wedge cuts for the ACW-PTO are prepared using a Bovie laterally and medially, and a small ACL saw is used to remove the cortical wedge. The ACW-PTO is closed and fixed with 3 large Richard staples, and a 10-mm low profile reamer is hand reamed to clear the tunnel for graft passage. The lateral root transtibial repair is fixed to the lateral tibial cortex with an EndoButton. The ACLR graft is passed into the femoral tunnel and fixed with a titanium interference screw. The ACLR graft is cycled and fixed in full extension on the tibia with a post and washer. The LET graft is fixed last at the previously marked spot on the femur with the knee in 20° of knee flexion and neutral rotation. Deep and superficial tissues are closed with suture.