The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence

Thomas Tischer, Jochen Paul, Dietrich Pape, Michael T Hirschmann, Andreas B Imhoff, Stefan Hinterwimmer, Matthias J Feucht, Thomas Tischer, Jochen Paul, Dietrich Pape, Michael T Hirschmann, Andreas B Imhoff, Stefan Hinterwimmer, Matthias J Feucht

Abstract

Background: Failure rates of knee ligament surgery may be high, and the impact of osseous alignment on surgical outcome remains controversial. Basic science studies have demonstrated that osseous malalignment can negatively affect ligament strain and that realignment procedures may improve knee joint stability.

Hypothesis/purpose: The purpose of this review was to summarize the clinical evidence concerning the impact of osseous malalignment and realignment procedures in knee ligament surgery. The hypotheses were that lower extremity malalignment would be an important contributor to knee ligament surgery failure and that realignment surgery would contribute to increased knee stability and improved outcome in select cases.

Study design: Systematic review; Level of evidence, 4.

Methods: According to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic electronic search of the PubMed database was performed in November 2015 to identify clinical studies investigating (A) the influence of osseous alignment on postoperative stability and/or failure rates after knee ligament surgery and (B) the impact of osseous realignment procedures in unstable knees with or without additional knee ligament surgery on postoperative knee function and stability. Methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and the Coleman Methodological Score (CMS).

Results: Of the 1466 potentially relevant articles, 28 studies fulfilled the inclusion and exclusion criteria. Average study quality was poor (CMS, 40). For part A, studies showed increased rerupture rate after anterior cruciate ligament (ACL) replacement in patients with increased tibial slope. Concerning the posterior cruciate ligament (PCL)/posterolateral corner (PLC)/lateral collateral ligament (LCL), varus malalignment was considered a significant risk factor for failure. For part B, studies showed decreased anterior tibial translation after slope-decreasing high tibial osteotomy in ACL-deficient knees. Correcting varus malalignment in PCL/PLC/LCL instability also showed increased stability and better outcomes.

Conclusion: In cases of complex knee instability, the 3-dimensional osseous alignment of the knee should be considered (eg, mechanical weightbearing line and tibial slope). In cases of failed ACL reconstruction, the tibial slope should be considered, and slope-reducing osteotomies are often helpful in the patient revised multiple times. In cases of chronic PCL and/or PLC instability, osseous correction of the varus alignment may reduce the failure rate and is often the first step in treatment. Changes in the mechanical axis should be considered in all cases of instability accompanied by early unicompartmental osteoarthritis.

Keywords: ACL revision; high tibial osteotomy; knee instability; osseous geometry; tibial slope.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: T.T. is a consultant for Arthrex and Bauerfeind. J.P. is a consultant for Stryker. S.H. is a consultant for Arthrex. M.T.H. is a consultant for Depuy Synthes and Smith & Nephew; received a research grant from Mathys; and is a paid speaker for Arthrex and Zimmer. A.B.I. is a consultant for Arthrex and receives royalties from Arthrex and Arthrosurface.

Figures

Figure 1.
Figure 1.
Flowchart of the search strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Figure 2.
Figure 2.
(A) Coronal alignment is analyzed using the weightbearing line of the lower limb (a) and the mechanical tibiofemoral angle (x), which is defined as the angle between the mechanical axes of the femur (b) and tibia (c), respectively. (B) The tibial slope is defined as the angle (x) between a line (b) perpendicular to the proximal anatomical axis of the tibia (a) and a tangent along the tibial plateau (c).

References

    1. Agneskirchner JD, Hurschler C, Stukenborg-Colsman C, Imhoff AB, Lobenhoffer P. Effect of high tibial flexion osteotomy on cartilage pressure and joint kinematics: a biomechanical study in human cadaveric knees. Winner of the AGA-DonJoy Award 2004. Arch Orthop Trauma Surg. 2004;124:575–584.
    1. Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P. The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy. 2007;23:852–861.
    1. Amis AA. Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2013;21:197–205.
    1. Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J Sports Med. 2007;35:1844–1850.
    1. Ayerza MA, Suarez F, Costa-Paz M, Muscolo DL. Can wedge osteotomy correct depression of the lateral tibial plateau mimicking posterolateral rotatory knee instability? Clin Orthop Relat Res. 2012;470:986–992.
    1. Badhe NP, Forster IW. High tibial osteotomy in knee instability: the rationale of treatment and early results. Knee Surg Sports Traumatol Arthrosc. 2002;10:38–43.
    1. Björnsson H, Andernord D, Desai N, et al. No difference in revision rates between single- and double-bundle anterior cruciate ligament reconstruction: a comparative study of 16,791 patients from the Swedish National Knee Ligament Register. Arthroscopy. 2015;31:659–664.
    1. Cantin O, Magnussen RA, Corbi F, Servien E, Neyret P, Lustig S. The role of high tibial osteotomy in the treatment of knee laxity: a comprehensive review. Knee Surg Sports Traumatol Arthrosc. 2015;23:3026–3037.
    1. Christensen JJ, Krych AJ, Engasser WM, Vanhees MK, Collins MS, Dahm DL. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Am J Sports Med. 2015;43:2510–2514.
    1. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports. 2000;10:2–11.
    1. Crawford SN, Waterman BR, Lubowitz JH. Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy. 2013;29:1566–1571.
    1. Dean CS, Liechti DJ, Chahla J, Moatshe G, LaPrade RF. Clinical outcomes of high tibial osteotomy for knee instability: a systematic review. Orthop J Sports Med. 2016;4:2325967116633419.
    1. Dejour D, Saffarini M, Demey G, Baverel L. Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc. 2015;23:2846–2852.
    1. Dejour H, Neyret P, Boileau P, Donell ST. Anterior cruciate reconstruction combined with valgus tibial osteotomy. Clin Orthop Relat Res. 1994;299:220–228.
    1. El-Azab H, Halawa A, Anetzberger H, Imhoff AB, Hinterwimmer S. The effect of closed- and open-wedge high tibial osteotomy on tibial slope: a retrospective radiological review of 120 cases. J Bone Joint Surg Br. 2008;90:1193–1197.
    1. Faschingbauer M, Sgroi M, Juchems M, Reichel H, Kappe T. Can the tibial slope be measured on lateral knee radiographs? Knee Surg Sports Traumatol Arthrosc. 2014;22:3163–3167.
    1. Feucht MJ, Mauro CS, Brucker PU, Imhoff AB, Hinterwimmer S. The role of the tibial slope in sustaining and treating anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc. 2013;21:134–145.
    1. Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007;35:1443–1449.
    1. Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD. Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med. 2004;32:376–382.
    1. Griffith TB, Allen BJ, Levy BA, Stuart MJ, Dahm DL. Outcomes of repeat revision anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:1296–1301.
    1. Hetsroni I, Lyman S, Pearle AD, Marx RG. The effect of lateral opening wedge distal femoral osteotomy on medial knee opening: clinical and biomechanical factors. Knee Surg Sports Traumatol Arthrosc. 2014;22:1659–1665.
    1. Hinckel BB, Demange MK, Gobbi RG, Pecora JR, Camanho GL. The effect of mechanical varus on anterior cruciate ligament and lateral collateral ligament stress: finite element analyses. Orthopedics. 2016;39:e729–e736.
    1. Hinterwimmer S, Beitzel K, Paul J, et al. Control of posterior tibial slope and patellar height in open-wedge valgus high tibial osteotomy. Am J Sports Med. 2011;39:851–856.
    1. Hohmann E, Bryant A, Imhoff AB. The effect of closed wedge high tibial osteotomy on tibial slope: a radiographic study. Knee Surg Sports Traumatol Arthrosc. 2006;14:454–459.
    1. Hohmann E, Bryant A, Reaburn P, Tetsworth K. Does posterior tibial slope influence knee functionality in the anterior cruciate ligament-deficient and anterior cruciate ligament-reconstructed knee? Arthroscopy. 2010;26:1496–1502.
    1. Hudek R, Schmutz S, Regenfelder F, Fuchs B, Koch PP. Novel measurement technique of the tibial slope on conventional MRI. Clin Orthop Relat Res. 2009;467:2066–2072.
    1. Kean CO, Birmingham TB, Garland JS, et al. Moments and muscle activity after high tibial osteotomy and anterior cruciate ligament reconstruction. Med Sci Sports Exerc. 2009;41:612–619.
    1. Kim SJ, Moon HK, Chun YM, Chang WH, Kim SG. Is correctional osteotomy crucial in primary varus knees undergoing anterior cruciate ligament reconstruction? Clin Orthop Relat Res. 2011;469:1421–1426.
    1. LaPrade RF, Engebretsen L, Johansen S, Wentorf FA, Kurtenbach C. The effect of a proximal tibial medial opening wedge osteotomy on posterolateral knee instability: a biomechanical study. Am J Sports Med. 2008;36:956–960.
    1. Lattermann C, Jakob RP. High tibial osteotomy alone or combined with ligament reconstruction in anterior cruciate ligament-deficient knees. Knee Surg Sports Traumatol Arthrosc. 1996;4:32–38.
    1. Lee SH, Jung YB, Lee HJ, Jung HJ, Kim SH. Revision posterior cruciate ligament reconstruction using a modified tibial-inlay double-bundle technique. J Bone Joint Surg Am. 2012;94:516–522.
    1. Li Y, Hong L, Feng H, Wang Q, Zhang H, Song G. Are failures of anterior cruciate ligament reconstruction associated with steep posterior tibial slopes? A case control study. Chin Med J (Engl). 2014;127:2649–2653.
    1. Li Y, Hong L, Feng H, et al. Posterior tibial slope influences static anterior tibial translation in anterior cruciate ligament reconstruction: a minimum 2-year follow-up study. Am J Sports Med. 2014;42:927–933.
    1. Li Y, Zhang H, Zhang J, Li X, Song G, Feng H. Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in young patients with anterior cruciate ligament-deficient knees: a systematic review. Arthroscopy. 2015;31:507–519.
    1. Lipps DB, Wilson AM, Ashton-Miller JA, Wojtys EM. Evaluation of different methods for measuring lateral tibial slope using magnetic resonance imaging. Am J Sports Med. 2012;40:2731–2736.
    1. Marriott K, Birmingham TB, Kean CO, Hui C, Jenkyn TR, Giffin JR. Five-year changes in gait biomechanics after concomitant high tibial osteotomy and ACL reconstruction in patients with medial knee osteoarthritis. Am J Sports Med. 2015;43:2277–2285.
    1. MARS Group, Wright RW, Huston LJ, et al. Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med. 2010;38:1979–1986.
    1. Marx RG, Wilson SM, Swiontkowski MF. Updating the assignment of levels of evidence. J Bone Joint Surg Am. 2015;97:1–2.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006–1012.
    1. Naudie DD, Amendola A, Fowler PJ. Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med. 2004;32:60–70.
    1. Noyes FR, Barber SD, Simon R. High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees. A two- to seven-year follow-up study. Am J Sports Med. 1993;21:2–12.
    1. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med. 2006;34:553–564.
    1. Noyes FR, Barber-Westin SD. Posterior cruciate ligament revision reconstruction, part 1: causes of surgical failure in 52 consecutive operations. Am J Sports Med. 2005;33:646–654.
    1. Noyes FR, Barber-Westin SD, Albright JC. An analysis of the causes of failure in 57 consecutive posterolateral operative procedures. Am J Sports Med. 2006;34:1419–1430.
    1. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28:282–296.
    1. Oiestad BE, Engebretsen L, Storheim K, Risberg MA. Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med. 2009;37:1434–1443.
    1. Petrigliano FA, Suero EM, Voos JE, Pearle AD, Allen AA. The effect of proximal tibial slope on dynamic stability testing of the posterior cruciate ligament– and posterolateral corner–deficient knee. Am J Sports Med. 2012;40:1322–1328.
    1. Reichwein F, Nebelung W. High tibial flexion osteotomy for revision of posterior cruciate ligament instability [in German]. Unfallchirurg. 2007;110:597–602.
    1. Saito K, Hatayama K, Terauchi M, Hagiwara K, Higuchi H, Takagishi K. Clinical outcomes after anatomic double-bundle anterior cruciate ligament reconstruction: comparison of extreme knee hyperextension and normal to mild knee hyperextension. Arthroscopy. 2015;31:1310–1317.
    1. Shelburne KB, Kim HJ, Sterett WI, Pandy MG. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res. 2011;29:223–231.
    1. Shelburne KB, Pandy MG, Torry MR. Comparison of shear forces and ligament loading in the healthy and ACL-deficient knee during gait. J Biomech. 2004;37:313–319.
    1. Sonnery-Cottet B, Mogos S, Thaunat M, et al. Proximal tibial anterior closing wedge osteotomy in repeat revision of anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42:1873–1880.
    1. van de Pol GJ, Arnold MP, Verdonschot N, van Kampen A. Varus alignment leads to increased forces in the anterior cruciate ligament. Am J Sports Med. 2009;37:481–487.
    1. Voos JE, Suero EM, Citak M, et al. Effect of tibial slope on the stability of the anterior cruciate ligament–deficient knee. Knee Surg Sports Traumatol Arthrosc. 2012;20:1626–1631.
    1. Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP. Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament–reconstructed patient. Am J Sports Med. 2013;41:2800–2804.
    1. Williams RJ, 3rd, Kelly BT, Wickiewicz TL, Altchek DW, Warren RF. The short-term outcome of surgical treatment for painful varus arthritis in association with chronic ACL deficiency. J Knee Surg. 2003;16:9–16.
    1. Won HH, Chang CB, Je MS, Chang MJ, Kim TK. Coronal limb alignment and indications for high tibial osteotomy in patients undergoing revision ACL reconstruction. Clin Orthop Relat Res. 2013;471:3504–3511.
    1. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003;85-A:1–3.
    1. Wright RW, Gill CS, Chen L, et al. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012;94:531–536.
    1. Zaffagnini S, Bonanzinga T, Grassi A, et al. Combined ACL reconstruction and closing-wedge HTO for varus angulated ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc. 2013;21:934–941.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera