Osteotomies in the ACL-deficient knee
Historically, osteotomies have been used for localized medial and lateral compartment gonarthrosis with varus and valgus malalignment, due to their ability to redistribute abnormal mechanical forces across the joint. However, over the last several years, the indications for high tibial osteotomy (HTO) have expanded to include cases of concomitant varus malalignment with ACL insufficiency. Although a general consensus on what is the optimal surgical technique is difficult to determine from the literature, there is consensus that the osteotomy can provide an accurate coronal and sagittal correction, while preventing an unintended alteration of the posterior tibial slope. Because of the role of posterior tibial slope in ACL failure, deflection anterior closing-wedge HTO with or without tibial tubercle detachment, combined with revision ACL reconstruction, has been proposed as an option for the treatment of multiple-failed ACL reconstruction with no bony or ligamentous abnormalities other than posterior slope >10-13°. However, due to the technical complexity of the surgical procedure and the lack of solid clinical evidence, it should be performed carefully only after accurate patient selection and counseling, preoperative planning, intraoperative technical caution, and careful follow-up.
