Current Concepts in Anterior Tibial Closing Wedge Osteotomies for Anterior Cruciate Ligament Deficient Knees

Abstract

Purpose of review: Anterior closing wedge osteotomies (ACWO) are utilized to better restore knee stability and in situ forces on anterior cruciate ligament (ACL) grafts during ACL revision reconstruction while reducing the risk of retearing and subsequent revision procedures. However, clinical outcomes following ACWO for patients undergoing ACL reconstruction remains largely limited. The purpose of this review was to provide a concise overview of the current literature on indication, techniques, and outcomes following ACWO in ACL-deficient patients undergoing primary or revision ACL reconstruction while discussing the authors' preferred technique to ACWO during a staged ACL revision reconstruction.

Recent findings: Currently available clinical studies and case reports have demonstrated ACWO to improve knee stability and outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction with low complication rates. The ACWO provides an adjunct surgical option to decrease graft failure while improving knee stability and post-surgical outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction. Further investigations are warranted to validate currently reported outcomes following ACWO in higher-level clinical studies with longer-term follow-up.

Keywords: ACL-deficient knee; High tibial osteotomy; Osteotomy; Posterior tibial slope; Slope reduction; Varus.

Conflict of interest statement

Amar Vadhera, Derrick Knapik, Safa Gursoy, Daniel Farivar, and Allison Perry declare that they have no conflict of interest.

Jorge Chahla is a paid consultant of Arthrex, Inc, CONMED Linvatec, Ossur, and Smith & Nephew, outside of the submitted work. He is a board or committee member of American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine.

Brian Cole is Dr. Cole reports receiving research support or royalties, serves as a paid consultant, or other financial support from Aesculap, NIH, Operative Techniques in Sports Medicine, Ossio, Regentis, Smith and Nephew, Arthrex Inc, Elsevier publishing, Bandgrip Inc, Acumed LLC, Encore Medical, LP, GE Healthcare, Merck Sharp & Dohme Corporation, SportsTek Medical, Inc, and Vericel Corporation, outside of the submitted work.

© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

Figures

Fig. 1

The anterior closing wedge osteotomy can be performed at (A), below (B), or above (C) the tibial tubercle (red) and aimed at the posterior cortex

Fig. 2

Posterior tibial slope is measured by calculating the angle between the proximal anatomic tibial axis the line defining the posterior inclination of the tibial plateau (red). The planned osteotomy is visualized (blue), and the tibial tubercle is noted (brown)

Fig. 3

A Cushing elevator (arrow) is passed proximal to the tendon insertion onto the tibial tubercle (TT), protecting the patellar tendon (PT) by isolating the distal extent of the tendon. Standard patient orientation: bottom of the image is distal (D), top of the image is proximal (P), left side of image is lateral (L), and right is medial (M)

Fig. 4

The osteotomy site was marked with 4 converging 2.0-mm distal Kirschner wires (A) perpendicular to the shaft of the tibia using fluoroscopic guidance (B)

Fig. 5

The osteotomy is performed at the proximal (A) and distal (B) aspects of the tibial tubercle using an oscillating saw at the position of the Kirschner wires without violating the posterior cortex to protect the popliteal vasculature

Fig. 6

View of the final construct fixated with three staples, two inserted medial and one lateral to the tibial tubercle

Fig. 7

Postoperative anteroposterior (AP) and lateral radiographs demonstrate a decrease in posterior along with three Richard staples, interference screw, and endobutton