Combined arthroscopic ACLR and medial open wedge HTO Dr Vipul Vijay Consultant Indraprastha Apollo Hospital, Sarita Vihar, New Delhi

Combined ACL tear & medial joint OA PROBLEM STATEMENT Chronic ACL deficient knee has high chances of progression to osteoarthritis (OA) ACLR stalls OA progression, but medial compartment OA with varus deformity needs realignment osteotomy. Combined ACL tear & OA – ACL + HTO.

Combined ACLR & HTO PROBLEM STATEMENT Whether both procedures should be staged or simultaneous. Whether internal fixation is to be used for HTO.

Materials & methods All patients between 20 to 55 with instability and knee pain assessed clinically. Detailed knee examination – anterior/posterior and varus/valgus instability, medial jt line tenderness, ROM, IKDC and KOOS. All patients underwent MRI and standing AP & lateral radiographs.

Materials & methods Patients with Radiologic and clinical evidence of OA (Kellegren Lawrence Grade II/III) MRI proven ACL tear were considered for inclusion in this study.

Exclusion criteria A history of previous ACL or any other ligament reconstruction Grade IV OA Presence of peri-articular implant Severe varus deformity (> 20 degrees) Lateral joint line opening.

Surgery Any unstable cartilage lesions were debrided to stable margins. Small cartilage (<1 cm2) lesions - microfracture after stabilization the edges. Larger lesions - debridement alone. Conservative resection of meniscus

Salient features of the technique ACL first. Correct positioning of the tibial tunnel for ACL graft – is the key. The guide is fixed at 40-45 degree angle (acuter than the usual 50-55 degrees), Starting point of tunnel is proximal than usual. Rest routine ACL, bio-screw used at tibial side and endobutton on femoral side.

Salient features of the technique Approx 1 cm bone b/w tibial tunnel & for starting point of osteotomy is left. Entry point (red line) made distal to tibial tunnel of ACLR (yellow circle). Proximal to tibial tubercle (leaving a safe gap of about 10 mm).

Salient features of the technique 4.5mm drill bit obliquely directed to the head of the fibula. Oscillating saw - advanced till two-thirds of tibia Avoid breaching the lateral tibial cortex. Completion of osteotomy by osteoclasis by valgus stress.

Salient features of the technique Opening maintained by lamina spreader. TCP wedge (Otis™) was inserted in the gap. TCP wedge maintained in position by - constant tendency of the osteotomized surfaces to go in varus - exerting a compressive effect at the osteotomy.

Results - KOOS S.No. KOOS PARAMETERS PRE OP KOOS SCORE 3 MONTHS FOLLOW UP SCORE 1 YEAR FOLLOW UP SCORE 1 Pain 34 76 89 2 Symptoms 29 60 92 3 ADL 31 55 87 4 Sports/Recreation 24 53 81 5 QOL 27 67

Results - IKDC S.No. Parameters No difficulty at all Minimally difficult Moderately difficult Extremely difficult Unable to do A Go upstairs 31(77.5%) 9(22.5%) B Go down stairs 33(82.5) 7(17.5%) C Kneeling 29(76.5) 11(27.5%) D Squat 26(65%) 14(35%) E Sit with knee bent 34(85%) 6(15%) F Rise from a chair 9 (22.5%) G Run straight ahead 27 (67.5%) 12(30%) 1(2.5%) H Jump and land on involved knee 25(62.5%) 10(20%) 5(12.5%) I Stop and start quickly

Results 40 patients. Mean age - 37.3 years (range 30 to 55 years). Last follow-up was an average of 14.4months (range 11 to 17 months). Mean varus angle correction of 90 (10.50 to 1.50). Mechanical axis of the knee restored from average of 1720 to 181.50.

Results Significant improvement in knee score (KOOS and IKDC) after the surgery (p<0.05). Average time for radiological union of osteotomy - 3.56 months. Anterior tibial translation was improved (Grade 3 decreased from 60% to 10%). No intraoperative complications and slippage of the synthetic graft was noted in any case.

Combined ACLR and HTO – single stage O’ Niell described good results with simultaneous ACLR & HTO. Williams et al – Combined ACLR & HTO fared better than isolated HTO. Bonin et al – reported 42% return to intensive sports in combined group. O'Neill DF. Valgus osteotomy with anterior cruciate ligament laxity. Clin Orthop Relat Res, 1992. Williams III RJ. The short-term outcome of surgical treatment for painful varus arthritis in association with chronic ACL deficiency. J Knee Surg, 2003. Bonin N. Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 years follow-up. Knee, 2004.

Disadvantages of internal fixation in HTO An interference of the internal fixation device with the tibial tunnel of ACLR. Increased chances of infection with the use of hardware. Need for implant removal. Larger skin incision and soft tissue dissection. Possible difficulty in performing future MRI (esp. if SS plates used for fixation). Increased C arm exposure.

β-TCP wedge (β-Ca3(PO4)2) Eliminates the risk of contamination of human or animal origin (AIDS, hepatitis, bovine or ovine spongiform encephalopathies). Very similar to the inorganic bone phase. Facilitates colonization of the implant surface by osteoblasts. Held in position by compressive action of quadriceps and tendency of fragments to collapse in varus.

Case 1 38 year old female with pre operative varus deformity and medial joint OA on left side Post operative radiograph showing the correction of the deformity with medial open wedge HTO. Endobutton visible on the lateral femoral cortex.

Case 2 – Pre – op & post op standing scanograms United osteotomy 42 year old male with chronic ACL rupture and medial compartment of OA.

Conclusion Simultaneous combined ACLR with HTO (using TCP wedge, without any hardware) is a reliable method that prevents rapid progression of OA. It reliably corrects varus deformity and obviates the use of any hardware. TCP wedge circumvents problems related to hardware. No complications of wedge slippage or loss of correction.

Thank you

The solution... An arthroscopic ACLR using a single bundle (quadrupled) of hamstring tendon graft with simultaneous medial open wedge HTO (using a tricalcium phosphate wedge), without any plate fixation.

OA with ACL tear Combination of ACL tear and isolated medial compartment OA is not uncommon. Combined ACLR with HTO is agreed treatment but debate is on Timing of the two surgeries (simultaneous v/s staged) Use of implant for fixation of the HTO