Concurrent High Tibial Osteotomy, Anterior Cruciate Ligament Reconstruction, and Medial Meniscus Posterior Root Repair

Abstract

Medial meniscus posterior root tears and anterior cruciate ligament (ACL) injuries disrupt knee biomechanics and accelerate joint degeneration, particularly in the presence of varus malalignment. This technical note describes a combined surgical approach that integrates medial meniscus posterior root repair, ACL reconstruction, and high tibial osteotomy (HTO) to restore joint stability, optimize load distribution, and prevent osteoarthritis progression. The procedure is performed arthroscopically using anteromedial and anterolateral portals. Meniscal root and ACL footprints are prepared, and sutures are passed using a loop‐stitch technique. A biplanar high tibial osteotomy is then performed distal to the guide pins to correct varus alignment, with plate fixation positioned posteriorly and distally for optimal stability. The meniscal root tunnel is drilled at a 45° angle, followed by ACL tunnel placement and graft fixation using interference screws and a suspensory button system. This combined approach enables simultaneous restoration of meniscal function, knee stability, and mechanical alignment, potentially improving long‐term outcomes compared with isolated procedures.

Medial meniscal root tears (MMRTs) represent a significant cause of knee dysfunction, accelerating cartilage degeneration and osteoarthritis progression when untreated. These effects are compounded in cases with concurrent anterior cruciate ligament (ACL) injuries and varus malalignment, creating a biomechanical environment that demands comprehensive surgical management. Our technique combines an arthroscopic medial meniscal root repair, ACL reconstruction, and high tibial osteotomy (HTO) in a single procedure to address this complex pathology. The root repair restores meniscal hoop stress mechanics through suture fixation, while anatomic ACL reconstruction reestablishes rotational and translational stability. The HTO component corrects varus deformity, redistributing load from the compromised medial compartment to optimize healing conditions for both the repaired meniscus root and ACL graft.

Preoperative evaluation confirms the complete triad of pathologies through advanced imaging. An magnetic resonance imaging reveals a complete medial meniscal radial root tear with >3 mm of extrusion, along with an ACL tear and increased anterior tibial translation (Figure 1). Standing full‐length radiographs reveal severe varus malalignment, with the mechanical axis passing medial to the medial tibial plateau, exacerbating medial compartment overload (Figure 2). This combined approach is specifically designed for patients presenting with this challenging combination of MMRT, ACL insufficiency, and varus malalignment, to restore knee stability, preserve meniscal function, and prevent progressive or slow joint degeneration (Video 1).

FIGURE 1.

MRI findings of meniscal root tear and ACL rupture. (A‐C) Multiplanar MRI showing medial meniscal root tear (red arrow, (A) axial view, (B) coronal view, (C) sagittal view of lateral intact meniscus) with associated medial meniscal root extrusion (B). (D‐F) Sequential sagittal T2‐weighted images (medial to lateral) showing complete ACL disruption (yellow arrow). (ACL, anterior cruciate ligament; ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; MRI, magnetic resonance imaging; P, patella; POS, posterior; PT, the proximal tibia.)

FIGURE 2.

Preoperative evaluation including (A) clinical appearance, (B) standing long‐leg alignment radiographs, (C) Rosenberg view, and (D) true lateral radiographs. The patient shows bilateral genu varum deformity. The mechanical axis passes medial to the knee joint on the right side (B). Rosenberg and true lateral radiographs reveal grade II Kellgren‐Lawrence osteoarthritis (C,D). (ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; P, patella; POS, posterior; PT, the proximal tibia.)

VIDEO 1.

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Initial diagnostic arthroscopy through anterolateral and anteromedial portals allowed systematic assessment of intra‐articular structures, with particular attention to the lateral compartment for cartilage integrity, given the anticipated postoperative load shift after high tibial osteotomy. The medial compartment was examined to determine cartilage and meniscal status, with meniscal root repair indicated for International Cartilage Repair Society grades I‐III in the presence of adequate tissue quality. Following confirmation of a root tear, edge debridement and anatomic footprint preparation were performed through a posteromedial portal, while partial preservation of native anterior cruciate ligament fibers was prioritized with selective debridement of irreparably damaged tissue. A medial longitudinal incision facilitated subperiosteal exposure of the proximal tibia, distal release of the medial collateral ligament, identification of the pes anserinus, and harvesting of gracilis and semitendinosus tendons for preparation of a quadrupled hamstring autograft. Root repair sutures were passed using a lasso suture passer with 2 fixation points, while the osteotomy was executed with parallel guide wires directed toward the proximal tibiofibular joint and stabilized using a TomoFix plate positioned more distally and posteriorly than in the conventional technique to enhance construct stability. Tunnel creation followed plate fixation, with the meniscal root tunnel drilled first adjacent to the anterior plate border and the tibial anterior cruciate ligament tunnel drilled anterior to this trajectory. Root fixation was achieved with an interference screw augmented by cortical screw‐and‐washer backup fixation, and anterior cruciate ligament graft fixation was subsequently performed using an interference screw in the femoral tunnel and an EndoButton for tibial fixation, ensuring stable restoration of both root and ligament function while correcting malalignment. Video content can be viewed at https://doi.org/10.1002/atn2.70123.

Key technical considerations include the sequence of procedures, with initial arthroscopic assessment of meniscal and chondral status, followed by careful planning of tunnel trajectories to avoid convergence between the ACL reconstruction and meniscal root repair. The osteotomy is performed after thorough preoperative planning to achieve precise correction of the mechanical axis. This integrated strategy addresses all components of the pathological cascade while respecting the biological and biomechanical requirements of each procedure, creating optimal conditions for long‐term joint preservation.

SURGICAL TECHNIQUE

The patient is presented supine on a radiolucent operating table under spinal anesthesia. A tourniquet is applied at a pressure of 100 mm Hg above the patient's systolic blood pressure. Proper pelvic positioning (including femoral head visualization) must be confirmed to ensure accurate fluoroscopic alignment assessment throughout the procedure.

Step 1: Arthroscopic Evaluation and Preparation

Anterolateral and anteromedial arthroscopic portals are established for the initial diagnostic arthroscopy. A systematic joint evaluation is performed to identify associated pathologies. The lateral compartment is carefully assessed to evaluate cartilage status, as increased weight‐bearing forces would be transferred laterally after an HTO. Medial arthroscopy, followed, to examine both cartilage and meniscal status.

For meniscal root repair eligibility, International Cartilage Repair Society grades I‐III are considered acceptable. Meniscal tissue quality at the tear site is critically evaluated as a prognostic factor for failure risk. After root tear confirmation, edge debridement and footprint preparation are performed through a posteromedial portal under anterolateral visualization (Figure 3). A shaver is used to define the footprint, with concurrent preparation of the ACL attachment sites.

FIGURE 3.

Multimodal visualization of medial meniscal root tear. (A) Coronal T2‐weighted MRI showing high signal intensity at the medial posterior meniscal root (red arrow), consistent with a radial root tear. (B) Arthroscopic view in anterolateral portal through the anterolateral portal confirms a root tear (red arrow). (C) An anatomical model of a right knee illustrates the typical location of posterior root detachment. (ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; MM, medial meniscus; MRI, magnetic resonance imaging; P, patella; POS, posterior; PT, the proximal tibia.)

When feasible, the native ACL fibers are preserved. When necessary, only damaged portions are debrided, maintaining maximal native tissue integrity. The femoral ACL tunnel is then prepared within the anatomical footprint, completing the first arthroscopic phase (Figure 4).

FIGURE 4.

Multimodal visualization of ACL tear. (A) Sagittal T2‐weighted MRI showing an ACL tear (yellow arrow). (B) Arthroscopic view through the anterolateral portal confirms ACL tear (yellow arrow), empty notch sign. (C) Sequential reaming through accessory anteromedial portal showing preservation of the tunnel posterior wall. The 4.5 mm reamer (green arrow) showing anatomic placement at the junction of the lateral intercondylar ridge and bifurcate ridge. (ACL, anterior cruciate ligament; ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; MM, medial meniscus; MRI, magnetic resonance imaging; P, patella; POS, posterior; PT, the proximal tibia.)

Step 2: HTO Approach

A 6‐cm longitudinal incision is extended distally from the anteromedial portal. Subperiosteal exposure of the proximal medial tibia is performed. The medial collateral ligament (MCL) is preserved, with only its distal attachment partially released using an osteotome to facilitate access. The pes anserinus is identified after longitudinal splitting of the sartorius fascia. The distal attachments of the gracilis and semitendinosus are identified, and the hamstring tendons harvested using a closed tendon stripper. The ACL graft is then prepared in a four‐strand configuration and maintained under proper tension for use in the ACL reconstruction phase.

Step 3: Suture Passage

After the medial knee compartment is widened due to MCL release during the HTO approach, medial arthroscopy can be performed without requiring MCL pie‐crusting. Arthroscopy is resumed to complete root preparation. Using a lasso suture passer, 2 sutures are passed through the medial meniscus root, positioned 3 and 6 mm from the torn edge, employing the loop‐post technique. The root repair tunnel is not drilled at this stage.

Step 4: Osteotomy

A provisional plate is placed to precisely determine the osteotomy site. Two parallel guide pins are placed with the proximal tibiofibular joint as the target. The osteotomy is performed distal to the guide pins using a uniplanar technique, planned specifically distal to the tibial tuberosity. After completing the osteotomy with a safe intact lateral hinge, the correction angle is opened using an automatic lamina spreader (Figure 5). A TomoFix plate (DePuy, Warsaw, IN) is placed with the lamina spreader maintained in position.

FIGURE 5.

Right knee in supine position. Monoplanar high tibial osteotomy surgical technique. (A,B) Dual K‐wire placement (red arrows) referencing the PTFJ for osteotomy planning. (C,D) Monoplanar osteotomy performed distal to the tibial tuberosity. (E,F) Correction achieved with lamina spreader (green arrow), medial aspect of right. (ANT, anterior; DF, distal femur; K‐wire, Kirschner wire; LAT, lateral; MED, medial; MM, medial meniscus; P, patella; POS, posterior; PT, the proximal tibia; PTFJ, proximal tibiofibular joint.)

After plate placement, the proximal anterior screw is intentionally omitted. In the transverse arm of the plate, the middle screw is placed to a depth of 20 mm, the posterior screw is inserted at full length (40 mm), and the fourth screw is placed at the appropriate length (26 mm in this case). One cortical screw is placed distal to the osteotomy site to ensure plate‐to‐bone contact, followed by insertion of the 2 remaining distal locking screws. Limb alignment is checked using an alignment rod under fluoroscopy, with the target being the mechanical axis passing through the lateral tibial eminence. After alignment confirmation, the cortical screw is removed and replaced with a locking screw. Compared with the classic technique, the plate is positioned more distally and posteriorly.

Step 5: Tunnel Preparation

Once plate fixation is completed, tunnel preparation is performed. The meniscal root tunnel is drilled first at a 45° angle adjacent to the anterior border of the plate (Figure 6). The ACL tunnel is then drilled anterior to the root tunnel, also at a 45° angle (Figure 7). The root sutures are pulled through the root repair tibial tunnel, while the ACL graft sutures are passed through the tibial ACL tunnel and retrieved. The meniscal root is first fixed using an interference screw, supplemented with a metal screw and washer for backup fixation on the anteromedial tibial surface. Second, the ACL graft is passed into the femoral tunnel and fixed with an interference screw (Arthrex, Munich, Germany) in the tibial tunnel and an EndoButton (ConMed, New York) on the femur (Figure 8).

FIGURE 6.

(A) The tip‐aiming ACL tibial tunnel guide is inserted and positioned on the meniscal root insertion site arthroscopic view in anterolateral portal and (B) drawing and (C,D) moulage model. Meniscal root injury is identified as a yellow arrow. Meniscal root insertion identified as a green arrow. ACL tibial tunnel guide is identified as a red arrow. (ACL, anterior cruciate ligament; ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; MM, medial meniscus; P, patella; POS, posterior; PT, the proximal tibia.)

FIGURE 7.

Arthroscopic‐assisted tibial tunnel preparation in ACL reconstruction. (A) Arthroscopic view (anterolateral portal) showing tibial tunnel guide placement at the anatomical footprint at a 45° angle (remnant preserving technique). (B) Right knee in supine position. Medial knee exposure showing guide pin insertion through the tibial tunnel guide (brown arrow). (C) Illustration of tibial tunnel for ACL (blue arrow), tibial tunnel for medial meniscus root (red arrow). (ACL, anterior cruciate ligament; ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; MM, medial meniscus; P, patella; POS, posterior; PT, the proximal tibia.)

FIGURE 8.

Right knee in supine position Final fixation view following combined ACL reconstruction and medial meniscus root repair with monoplanar high tibial osteotomy. TomoFix plate fixation (red arrow), ACL reconstruction tunnel (green arrow), and medial meniscal root repair tunnel (orange arrow). (A,B) Medial meniscus fixation with screw/washer construct (black arrow) showing monoplanar osteotomy (pink arrow) positioned distal to the classic osteotomy site (blue arrow in B), with plate fixation extending posterior to the conventional position (purple arrow) (medial aspect of right knee). (ACL, anterior cruciate ligament; ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; MM, medial meniscus; P, patella; POS, posterior; PT, the proximal tibia.)

The final status of the ACLR and meniscal root repair is confirmed arthroscopically. The MCL is repaired over the plate, and vancomycin powder is applied to the plate. A drain is inserted subcutaneously, and all skin layers are closed. Local tranexamic acid is injected at the osteotomy site, and bupivacaine is injected around the wounds. Postoperative radiographs are shown (Figure 9).

FIGURE 9.

Postoperative radiography: (A) AP and (B) lateral view. TomoFix plate fixation (red arrow), monoplanar osteotomy (pink arrow). Screw/washer construct (black arrow), and Endobutton for ACL reconstruction (green arrow). (ANT, anterior; DF, distal femur; LAT, lateral; MED, medial; MM, medial meniscus; P, patella; POS, posterior; PT, the proximal tibia.)

Tables 1 and 2 summarize the advantages and disadvantages, as well as the pearls and pitfalls of the procedure. Table 3 lists the instruments utilized during the surgical technique.

TABLE 1.

Advantages and Disadvantages

Advantages	Disadvantages
Comprehensive Joint Preservation: Addresses meniscal function, ligament stability, and mechanical alignment in a single procedure, may reduce long‐term joint degeneration	Technically Demanding Procedure: Requires expertise in arthroscopy, ligament reconstruction, and osteotomy to ensure precise execution
Biomechanical Optimization: Meniscal root repair restores load transmission and shock absorption ACL reconstruction improves knee AP and rotational stability and reduces shear forces. HTO corrects malalignment, unloading the medial compartment and enhancing graft longevity	Longer Operative Time: Performing 3 complex procedures in 1 setting increases surgical duration, potentially raising the risk of complications such as infection, DVT, or arthrofibrosis
Prevention of Osteoarthritis Progression: By stabilizing the knee and offloading medial compartment and joint overload, this technique may help stabilizing the cartilage	Postoperative Rehabilitation Complexity: Combining meniscal repair, ACL reconstruction, and osteotomy necessitates a carefully structured rehabilitation protocol, balancing early motion with meniscus healing
Single‐Stage Surgery: Avoids multiple procedures, reducing overall recovery time and health care costs	Potential for Hardware‐Related Complications: Interference screws, plates, screw and washer may cause irritation, loosening, or the need for removal in some cases
Customized Osteotomy Approach: The monoplanar osteotomy with distal and posterior plate placement helps avoid tunnel osteotomy convergence	Higher Risk of Nonunion or Delayed Union: HTO carries a risk of nonunion, especially in patients with poor bone quality or suboptimal mechanical loading postoperatively

ACL, anterior cruciate ligament; DVT, deep vein thrombosis; HTO, high tibial osteotomy.

TABLE 2.

Pearls and Pitfalls

Pearls (Key Surgical Tips for Success)	Pitfalls (Common Errors to Avoid)
Comprehensive Preoperative Planning Obtain MRI to assess meniscal root integrity, ACL status, and articular cartilage condition Use long‐leg standing radiographs to evaluate varus malalignment and calculate the required correction angle	Inadequate Preoperative Assessment Failure to properly assess meniscal root damage or malalignment can compromise surgical outcome
Precise Arthroscopic Technique Utilize a posteromedial portal to achieve optimal visualization of the meniscal root for thorough debridement and anatomic footprint preparation (slightly offset from the cartilage) Preserve the ACL remnant while identifying and using the anatomical ACL footprint Perform dynamic arthroscopic assessment for roof impingement at full knee extension at the conclusion of the procedure	Technical Errors in Tunnel Placement Nonanatomic medialization or anteriorization of the meniscal root tunnel compromises biomechanical function Flexion contracture may result from roof impingement of the ACL graft
Optimal Tunnel Placement and Fixation Position the ACL tibial tunnel slightly anterior to the meniscal root tunnel, maintaining anatomical orientation to ensure correct graft trajectory Use a dual‐button suspensory fixation proximally and an interference screw distally for secure ACL graft tensioning Perform the HTO approach prior to meniscal root preparation to minimize tunnel convergence, release the MCL distally, and remove need to pie‐crusting of MCL	HTO Complications Due to Suboptimal Technique Inadequate osteotomy planning or overcorrection may lead to lateral compartment overload and patellofemoral pain Medial instability can result from iatrogenic MCL injury
Strategic Osteotomy Execution Conduct meticulous preoperative planning to determine wedge size using the Miniaci method Confirm the correction angle intraoperatively using an automatic lamina spreader prior to final plate fixation Posteriorly position the fixation plate to reduce the risk of tunnel‐implant convergence Drill the meniscal root tunnel at a 45° angle, adjacent to the anterior edge of the osteotomy plate, to avoid hardware interference Consider a slightly lower angle for ACL tibial tunnel guide and distalize the osteotomy plane to avoid convergence Prefer a monoplanar over biplanar osteotomy to reduce tunnel‐osteotomy overlap	Tunnel and Plate Convergence Improper planning may lead to convergence between the ACL tunnel, meniscal root tunnel, and osteotomy plate, resulting in hardware conflict and compromised fixation
Rehabilitation Considerations Initiate protected weight‐bearing postoperatively to facilitate healing of both the meniscal root repair and the osteotomy Emphasize quadriceps strengthening and gradual range of motion (ROM) restoration, while avoiding early excessive load	Inadequate Postoperative Protection Premature weight‐bearing or aggressive rehabilitation protocols can lead to meniscal repair failure and osteotomy nonunion

ACL, anterior cruciate ligament; HTO, high tibial osteotomy; MCL, medial collateral ligament; MRI, magnetic resonance imaging.

TABLE 3.

Instruments for a Combined Medial Meniscus Root Repair, Anterior Cruciate Ligament Reconstruction, and High Tibial Osteotomy

ACL Reconstruction		Meniscus Root		High Tibial Osteotomy
Hamstring autograft		FiberWire suture		Radiolucent table
Endobutton		Screw and washer		Lamina spreader
Interference screw		Reamer		TomoFix plate and screws
Steeper		ACL guide		Osteotomy
ACL guide		Lasso		Kershner wire
FiberWire suture		Screw driver		Drill bit 3.5 and 4.5
Nylone loop suture				Fluoroscopy
Sizer				Periosteal elevator
Arthroscopy set				Sleeve
ACL set				Alignment rod

ACL, anterior cruciate ligament.

Postoperative Rehabilitation Protocol

Patients are initially mobilized using a walker and instructed to maintain a nonweight‐bearing status for at least 2 months. Weight‐bearing is then gradually reintroduced, based primarily on the presence or absence of localized pain during ambulation.

Passive knee range of motion from 0° to 90° is initiated immediately after surgery. However, active knee flexion is initially restricted to minimize tension on the semimembranosus tendon and to protect the meniscal root repair. Isometric quadriceps exercises are encouraged early in the postoperative period to prevent muscle atrophy, whereas open‐chain strengthening exercises are deferred until 6 weeks postoperatively.

Patients typically return to work around 3 months after surgery, depending on their occupational demands and individual recovery progress.

DISCUSSION

Combined operative knee procedures are gaining popularity due to reduced overall costs and the need for fewer surgical interventions. However, a major concern remains the potential for an increased risk of complications. The combined surgical approach offers a comprehensive solution for patients presenting with concurrent meniscal root tears, ACL insufficiency, and varus malalignment.

This technique effectively addresses the underlying pathomechanics of knee instability, meniscal dysfunction, and abnormal load distribution, factors known to accelerate cartilage degeneration and lead to early osteoarthritis. ¹ , ² MMRTs significantly alter knee biomechanics by increasing tibiofemoral contact pressures and meniscal extrusion, which in turn accelerates cartilage wear and contributes to medial compartment osteoarthritis. ³ Repairing the meniscal root restores native load distribution, thereby mitigating these degenerative effects.

Evidence supports that an anatomic root repair not only reduces meniscal extrusion but also improves joint stability compared with partial meniscectomy. ⁴ Similarly, ACL reconstruction is critical for restoring knee stability, decreasing anterior tibial translation, and preventing secondary meniscal and chondral damage. ⁵ However, in patients with pre‐existing varus alignment, ACL reconstruction alone may not suffice, as persistent malalignment can contribute to graft failure and continued medial compartment overload. ⁶

An HTO plays a pivotal role in such cases by correcting varus deformity and unloading the medial compartment, thereby supporting both graft longevity and meniscal healing. ⁷ Recent studies have shown the efficacy of combined procedures in managing MMRTs with ACL deficiency, MMRT with varus alignment, and varus alignment with ACL insufficiency. For instance, Lee et al. reported superior functional and radiographic outcomes in patients undergoing simultaneous HTO and ACL reconstruction compared with ACL reconstruction alone. ⁸ Furthermore, correcting mechanical alignment enhances the biological environment for meniscal healing, as shown by higher healing rates and improved postoperative function in such patients. ⁹

Despite these benefits, single‐stage procedures involving medial meniscal root repair, ACL reconstruction, and HTO are technically demanding. Increased operative time and a more complex rehabilitation process may raise the risk of complications, including stiffness, delayed union, and implant‐related problems. ¹⁰ Therefore, careful patient selection is essential, taking into account factors such as age, bone quality, and pre‐existing cartilage damage.

This combined technique offers substantial biomechanical and clinical advantages. Nevertheless, further clinical studies are required to evaluate long‐term outcomes, including graft survival, meniscal healing rates, and osteotomy durability. Future research should aim to refine rehabilitation protocols to optimize the balance between early mobilization and tissue healing. Additionally, biologic augmentation strategies such as platelet‐rich plasma or bone marrow aspirate concentrate hold promise in enhancing healing and warrant further investigation. ¹¹

In the context of combined procedures, the angle and orientation of the tibial tunnel during ACL reconstruction are critical. A 45° angle in the sagittal plane is generally recommended for the tibial tunnel, as it offers a balance between anatomic graft placement and tunnel integrity. ¹² This angle helps avoid convergence with the HTO osteotomy plane, especially when the osteotomy is performed proximal to the tibial tuberosity. It also provides a more favorable graft trajectory for restoring native ACL biomechanics. ¹³ However, meticulous preoperative planning is required to ensure that the tibial tunnel does not interfere with hardware placement or compromise the stability of the osteotomy site.

The position of the osteotomy relative to the tibial tuberosity significantly impacts both mechanical correction and interaction with the ACL reconstruction tunnel. Performing the osteotomy distal to the tibial tuberosity (i.e., below the tubercle) can lead to anterior tibial slope changes, which may affect knee kinematics and potentially increase anterior tibial translation. ¹⁴ Recent studies have highlighted the importance of the osteotomy level in medial opening wedge HTO, particularly when combined with an ACL reconstruction. Liu et al. showed that performing the osteotomy proximal to the tibial tuberosity using personalized surgical guide plates helps preserve patellar height and does not increase posterior tibial slope, both of which are crucial for ACL graft protection and overall joint biomechanics. ¹⁵ Similarly, Sahanand et al. reported that ascending osteotomies provide better control of slope and patellar alignment compared with descending cuts, which are associated with patella baja and increased tibial slope. ¹⁶ These findings support the use of proximal, ascending osteotomy techniques to optimize outcomes in combined procedures involving ligament and meniscal root repairs.

The configuration of the osteotomy, uniplanar or biplanar, also has biomechanical and healing implications. Biplanar osteotomies involve an additional anterior cut, typically perpendicular to the sagittal plane, which increases the surface area for bone healing and provides improved rotational stability. ¹⁷ This is particularly important in combined procedures where early rehabilitation and weight‐bearing are desired. In contrast, uniplanar osteotomies offer technical simplicity but have a lower surface area for healing and provide less resistance to rotational forces. ¹⁸ In the setting of a concurrent ACL reconstruction, a biplanar osteotomy is often preferred for its mechanical advantages and lower risk of tunnel compromise due to its more controlled correction and fixation profile. ⁶

The single‐stage technique—integrating medial meniscal root repair, ACL reconstruction, and HTO—finds strong biomechanical justification in the findings of van der Wal et al. The systematic review of cadaveric studies highlights that untreated concomitant pathologies such as peripheral meniscus tears, meniscal ramp lesions, meniscal root tears, coronal plane malalignment (varus/valgus), and increased sagittal tibial slope significantly alter knee kinematics and amplify forces on both the native and reconstructed ACL. This underscores the inadequacy of isolated ACL reconstruction when such biomechanical stressors persist.

By repairing the medial meniscal root, we restore critical hoop stress transmission and reduce abnormal medial compartment loading—addressing one major source of increased ACL graft strain. Correcting varus malalignment via HTO redistributes load away from the medial compartment and also counteracts the deleterious effects of altered coronal and sagittal alignment on ACL force distribution. Taken together, these combined procedures directly target the modifiable factors identified in the cadaveric literature that predispose ACL reconstructions to overload and failure. ¹⁹

DISCLOSURES

The authors (F.V., S.A., S.M.M.S., O.S., L.V.T., R.F.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.