Slope-Correction Osteotomy with Lateral Extra-articular Tenodesis and Revision Anterior Cruciate Ligament Reconstruction Is Highly Effective in Treating High-Grade Anterior Knee Laxity

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Abstract

Background:

Both an elevated posterior tibial slope (PTS) and high-grade anterior knee laxity are often present in patients who undergo revision anterior cruciate ligament (ACL) surgery, and these conditions are independent risk factors for ACL graft failure. Clinical data on slope-correction osteotomy combined with lateral extra-articular tenodesis (LET) do not yet exist.

Purpose:

To evaluate the outcomes of patients undergoing revision ACL reconstruction (ACLR) and slope-correction osteotomy combined with LET.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 2016 and 2018, we performed a 2-stage procedure: slope-correction osteotomy was performed first, and then revision ACLR in combination with LET was performed in 22 patients with ACLR failure and high-grade anterior knee laxity. Twenty patients (6 women and 14 men; mean age, 27.8 ± 8.6 years; range, 18-49 years) were evaluated, with a mean follow-up of 30.5 ± 9.3 months (range, 24-56 months), in this retrospective case series. Postoperative failure was defined as a side-to-side difference of ≥5 mm in the Rolimeter test and a pivot-shift grade of 2 or 3.

Results:

The PTS decreased from 15.3° to 8.9°, the side-to-side difference decreased from 7.2 to 1.1 mm, and the pivot shift was no longer evident in any of the patients. No patients exhibited revision ACLR failure and all patients showed good to excellent postoperative functional scores (mean ± SD: visual analog scale, 0.5 ± 0.6; Tegner, 6.1 ± 0.9; Lysholm, 90.9 ± 6.4; Knee injury and Osteoarthritis Outcome Score [KOOS] Symptoms, 95.2 ± 8.4; KOOS Pain, 94.7 ± 5.2; KOOS Activities of Daily Living, 98.5 ± 3.2; KOOS Function in Sport and Recreation, 86.8 ± 12.4; and KOOS Quality of Life, 65.4 ± 14.9).

Conclusion:

Slope-correction osteotomy in combination with LET is a safe and reliable procedure in patients with high-grade anterior knee laxity and a PTS of ≥12°. Normal knee joint stability was restored and good to excellent functional scores were achieved after a follow-up of at least 2 years.

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Most cited references 38

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Rating systems in the evaluation of knee ligament injuries.

Y Tegner, J Lysholm (1985)

Many different methods of evaluating disability after knee ligament injury exist. Most of them differ in design. Some are based on only patients' symptoms. Other include patients' symptoms, activity grading, performance in a test, and clinical findings. The rating in these evaluating systems can be either numerical, as in a score, or binary, with yes/no answers. Comparison between a symptom-related score and a score of more complex design showed that the symptom-related score gave a more differentiated picture of the disability. It was also shown that the binary rating system gave less detailed information than a score and that differences in a binary rating can depend on at what level the symptoms are regarded as "significant." A new activity grading scale, where work and sport activities were graded numerically, was constructed as complement to the functional score. When evaluating knee ligament injuries, stability testing, functional knee score, performance test, and activity grading are all important. However, the relative importance varies during the course of treatment, and therefore they should not all be included in one and the same score.

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Effects of increasing tibial slope on the biomechanics of the knee.

J Giffin, Thore Zantop, T M Vogrin … (2004)

To determine the effects of increasing anterior-posterior (A-P) tibial slope on knee kinematics and in situ forces in the cruciate ligaments. Ten cadaveric knees were studied using a robotic testing system using three loading conditions: (1) 200 N axial compression; (2) 134 N A-P tibial load; and (3) combined 200 N axial and 134 N A-P loads. Resulting knee kinematics were determined before and after a 5-mm anterior opening wedge osteotomy. Resulting in situ forces in each cruciate ligament were determined. Tibial slope was increased from 8.8 +/- 1.8 degrees to 13.2 +/- 2.1 degrees, causing an anterior shift in the resting position of the tibia relative to the femur up to 3.6 +/- 1.4 mm. Under axial compression, the osteotomy caused a significant anterior tibial translation up to 1.9 +/- 2.5 mm (90 degrees ). Under A-P and combined loads, no differences were detected in A-P translation or in situ forces in the cruciates (intact versus osteotomy). Results suggest that small increases in tibial slope do not affect A-P translations or in situ forces in the cruciate ligaments. However, increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that increasing tibial slope may be beneficial in reducing tibial sag in a PCL-deficient knee, whereas decreasing slope may be protective in an ACL-deficient knee.

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Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties.

N. J. Collins, C. A. C. Prinsen, R E Christensen … (2016)

To conduct a systematic review and meta-analysis to synthesize evidence regarding measurement properties of the Knee injury and Osteoarthritis Outcome Score (KOOS).

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Author and article information

Journal

Journal ID (nlm-ta): Am J Sports Med

Journal ID (iso-abbrev): Am J Sports Med

Journal ID (publisher-id): AJS

Journal ID (hwp): amjsports

Title: The American Journal of Sports Medicine

Publisher: SAGE Publications (Sage CA: Los Angeles, CA )

ISSN (Print): 0363-5465

ISSN (Electronic): 1552-3365

Publication date (Electronic): 2 November 2020

Publication date (Print): December 2020

Volume: 48

Issue: 14

Pages: 3478-3485

Affiliations

[* ]Asklepios Clinic St Georg, Hamburg, Germany

[† ]University of Witten / Herdecke, Cologne Merheim Medical Center, Cologne, Germany

[‡ ]Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany

[§ ]Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

[ ]Investigation performed at Asklepios Clinic St Georg, Hamburg, Germany

Author notes

[*] [‖ ]Karl-Heinz Frosch, MD, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, Hamburg, 20246, Germany (email: unfallchirurgie@ 123456uke.de ).

R.A. and L.A. contributed equally to this article.

Article

Publisher ID: 10.1177_0363546520966327

DOI: 10.1177/0363546520966327

PMC ID: 7705640

PubMed ID: 33135908

SO-VID: 062b9ea8-58f0-454d-8a8c-eb7662a967f4

License:

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License ( https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access page ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

History

Date received : 16 April 2020

Date accepted : 23 July 2020

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Keywords: high-grade anterior knee instability,increased posterior tibial slope,revision anterior cruciate ligament reconstruction,slope-correction osteotomy

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Keywords: high-grade anterior knee instability, increased posterior tibial slope, revision anterior cruciate ligament reconstruction, slope-correction osteotomy

Slope-Correction Osteotomy with Lateral Extra-articular Tenodesis and Revision Anterior Cruciate Ligament Reconstruction Is Highly Effective in Treating High-Grade Anterior Knee Laxity

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Most cited references 38

Rating systems in the evaluation of knee ligament injuries.

Effects of increasing tibial slope on the biomechanics of the knee.

Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties.

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