The role of high tibial osteotomy in the ACL-deficient knee
Anterior cruciate ligament (ACL) de fi ciency in the setting of underlying lower extremity malalignment poses a special clinical challenge for surgeons because of the myriad considerations required to reconstruct a stable, durable, and functional knee. Many clinical and biomechanical studies have examined soft-tissue reconstructions for ACL de fi ciency, often without consideration for global coronal and/or sagittal plane deformities. Although their relative contributions continue to be debated, malalignment and ACL de fi ciency, both independently and in combination, can contribute to abnormal knee kinematics, which may hasten the development of osteoarthritis [7, 22, 29, 40]. Therefore, when considering a soft-tissue reconstruction, concomitant assessment of overall alignment is paramount to restoring a functional limb. Several authors have noted that soft-tissue procedures alone have a propensity for failure if concomitant malalignment, particularly varus, is not addressed [32, 34].
