Page 29 - ISAKOS 2019 Newsletter Vol II
P. 29

Completion of Osteotomy Fixation
A proximal anterior locking screw is placed, and the fixation is completed. The arthroscope can be used to visualize the tibial tunnel for potential screw penetration (Fig. 2). If the screw interferes with passage of the graft button fixation device, a shorter screw may be selected or the screw may not be placed at all, as the device provides adequate mechanical stability.
02 In case of convergence between the proximal anterior locking screw and the tibial tunnel, the screw can be visualized in the tunnel arthroscopically (white arrow).
Tensioning and Fixation of the Graft
The knee is brought to 30° of flexion, and posterior drawer stress is applied to the tibia. The tibial end of the graft is pulled distally and is tensioned adequately. While the graft is under tension, the tibial adjustable loop is tightened and is fixed on the tibial cortex (Fig. 3).
04 Anteroposterior radiograph (04A), lateral radiograph (04B), and standing long-leg radiograph (04C) made at 3 months after simultaneous ACL reconstruction with HTO.
Advantages of All-Inside ACL Reconstruction
All-inside ACL reconstruction using only the semitendinosus tendon has several advantages over conventional ACL reconstruction techniques using both the semitendinosus and gracilis tendons. The all-inside technique requires shorter tunnels and preserves proximal tibial bone stock. The short quadrupled graft that is needed for this technique allows harvesting of only one tendon, which causes less harvest-site morbidity and preserves knee flexor strength. The postoperative pain after all-inside ACL reconstruction has been shown to be less than that after conventional ACL reconstruction5.
The main advantage of the all-inside technique related to HTO is that the tibial tunnel does not converge with the proximal screws of the HTO fixation plate. In most cases, the proximal anterior screw remains below the 25-mm long tibial tunnel and does not interfere with the graft.
1. Noyes FR, Barber-Westin SD, Hewett TE. High Tibial Osteotomy and Ligament Reconstruction for Varus Angulated Anterior Cruciate Ligament-Deficient Knees. American Journal of Sports Medicine. 2001;28(3): 282-296. 2. Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am. 1979;10(3):585–608. 3. Li Y, 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(3):507-519. 4. Crawford MD, Diehl LH, Amendola A. Surgical Management and Treatment of the Anterior Cruciate Ligament–Deficient Knee with Malalignment. Clin Sports Med. 2017;36(1):119-133. 5. Connaughton AJ, Geeslin AG, Uggen CW. All-inside ACL reconstruction: How does it compare to standard ACL reconstruction techniques? J Orthop. 2017;14(2):241-246.
    03 Intraoperative view of the adjustable-loop fixation device (1), the orifice of the tibial tunnel (2), the osteotomy line (3), and the proximal anterior locking screw (4).
Advantages of HTO Combined with ACL Reconstruction
HTO combined with ACL reconstruction is a safe and effective one-stage procedure that has been associated with satisfactory functional outcomes and postoperative activity level scores when used for the treatment of patients who have symptomatic varus osteoarthritis in combination with anterior knee instability3. The procedure improves alignment, restores anterior knee stability, and helps to reduce the progression of OA4. As it is a one-stage operation, it has a lower cost compared with staged surgery (Fig. 4).

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