Coronal Limb Alignment and Indications for High Tibial Osteotomy in Patients Undergoing Revision ACL Reconstruction

Abstract

Background Failed ACL reconstruction frequently is accompanied by irreparable medial meniscal tear and/or visible osteoarthritis (OA) in the medial tibiofemoral joint. Thus, assessment for the presence of varus malalignment is important in caring for patients in whom revision ACL reconstruction is considered. Questions/purposesWe determined whether patients undergoing revision ACL reconstruction (1) have more frequent varus malalignment coupled with more severe degrees of medial meniscal injury and/or medial tibiofemoral OA, and (2) would meet potential indications for high tibial osteotomy more frequently than patients undergoing primary ACL reconstruction. Methods We compared 58 patients undergoing revision ACL reconstruction and 116 patients undergoing primary ACL reconstruction. The mechanical tibiofemoral angle and the weight loading line (%) of the knee were measured. Additionally, radiographic degrees of OA in the tibiofemoral joints, and meniscal conditions were assessed. Then, proportions of potential candidates for high tibial osteotomy between the two groups were compared based on the following indications: (1) weight loading line less than 5%, (2) weight loading line less than 25% and medial tibiofemoral OA Kellgren-Lawrence Grade 3 or greater, or (3) weight loading line less than 25% and Kellgren-Lawrence Grade 2 medial tibiofemoral OA plus subtotal or total medial meniscectomy status. Results The revision ACL reconstruction group had more frequent varus malalignment in terms of proportion of knees with more varus mechanical tibiofemoral angle than varus 5°(19% versus 8%, p = 0.029) and knees with weight loading line less than 25% (22% versus 9%, p = 0.011). This group also had more frequent high-grade injury of the medial meniscus (34% versus 16%, p = 0.007) and tended to have more frequent higher-grade radiographic OA at the medial tibiofemoral joint (19% versus 9%, p = 0.076). The percentage of patients meeting potential indications for high tibial osteotomy was greater in this group (14% versus 2%, p = 0.003). Conclusions We found that many patients undergoing revision ACL surgery may be reasonable candidates for concurrent high tibial osteotomy to address concomitant alignment and OA issues in the medial compartment. However, whether that additional intervention is offset by added risk and morbidity should be the focus of a future study, as it cannot be answered by a study of this design.

Association of Meniscal Status, Lower Extremity Alignment, and Body Mass Index With Chondrosis at Revision Anterior Cruciate Ligament Reconstruction

“…However, the current study did not evaluate the effect of realignment surgery, and more research is necessary to assess this possible relationship. Our findings are consistent with a recent study reporting that many rACLR patients are good candidates for high tibial osteotomy 45 .…”

Revision anterior cruciate ligament reconstruction does not prevent progression in one out of five patients of osteoarthritis: a meta-analysis of prevalence and progression of osteoarthritis

“…This higher incidence is also confirmed by several studies that compared the radiographic preoperative and postoperative results of revision ACL with a matched group of primary reconstruction,3 19 26 which showed an increased percentage of patients with varus malalignment and medial OA already at preoperative status, and an almost double-fold incidence of OA changes after 2.8–8 years. Moreover, the same studies reported a higher incidence of meniscal and chondral lesions in patients who sustain revision ACL reconstruction.…”

“…However, it could be assumed that the reported results could be non-specifically generalised for any kind of revision reconstruction, because no exclusion criteria based on surgical technique or patient's characteristics were applied. Also, the lack of OA evaluation with long leg radiographs could represent a bias for this study, as the importance of lower limb alignment in the primary and also revision ACL reconstruction has been extensively underlined 4 26 30–32. Lastly, the choice to consider 4 years as the minimum follow-up required for study inclusion reflects the paucity of the available literature, and could be considered a compromise between the necessity to obtain a sufficient number of studies and the minimum period to detect noticeable OA signs or OA progression.…”

Revision surgery for failed anterior cruciate ligament reconstruction with extension deficiency

“…[7][8][9][10] Among these, recurrent symptomatic instability typically requires a revision ACL reconstruction and is frequently combined with other complications such as meniscal tears, limitation of motion, or OA. 11 These combined | 2605 CHANG et Al.…”

“…However, a subset of patients needs additional surgery because of complications such as recurrent symptomatic instability, meniscal tears, osteoarthritis (OA), or stiffness . Among these, recurrent symptomatic instability typically requires a revision ACL reconstruction and is frequently combined with other complications such as meniscal tears, limitation of motion, or OA . These combined pathological conditions can affect the overall clinical results after revision ACL reconstruction.…”