Lucidi Gian Andrea, Zsidai Bálint, Winkler Philipp W, Godshaw Brian M, Hughes Jonathan D, Musahl Volker
Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Istituto Ortopedico Rizzoli, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna, Italy.
Video J Sports Med. 2022 Sep 6;2(5):26350254221102461. doi: 10.1177/26350254221102461. eCollection 2022 Sep-Oct.
Slope-correcting high tibial osteotomy (HTO) is gaining popularity for mitigating the impact of posterior tibial slope (PTS) on graft failure in patients requiring revision anterior cruciate ligament (ACL) reconstruction surgery. Biomechanical and clinical studies have demonstrated that PTS reduction results in decreased graft forces and satisfactory patient outcomes, making it an important technique in the setting of complex revision ACL reconstruction (ACL-R).
Slope-correcting HTO can be performed for the management of recurrent knee instability after ACL-R due to a high PTS of 12° or greater.
A 3- to 4-inch incision is made along the tibia using an anteromedial approach, and the exposed patellar tendon is protected using a retractor. The anterior compartment is exposed by an incision in the tibialis anterior fascia, followed by elevation of the tibialis anterior and placement of a Hohmann retractor. Subperiosteal elevation of the medial collateral ligament (MCL) is performed on the medial side of the tibial tubercle. The position of eventual screw fixation is marked, and a straight tubercle osteotomy is performed without anteriorization, leaving a freely exposed proximal tibia. Two K-wires are used to mark the location of the osteotomy. Soft tissue structures are protected with Hohmann retractors on both sides while using an oscillating saw to perform the osteotomy. A few degrees (1°-3°) of overcorrection are preferred. The osteotomy is completed, retaining 1cm of posterior hinge. The wedge is removed and reduced by hyperextending the knee under gentle manual traction. Pre-contoured, low-profile plates with locking screws are placed, with 3 screws proximally and another 3 distally. During concurrent ACL-R, the screws should leave room for drilling of the ACL tibial tunnel.
Studies investigating the effects of slope-correcting HTO concurrent to revision ACL-R have reported reduced anterior tibial translation and rotatory knee instability, improved patient-reported outcomes, and a reduction in graft failure risk.
DESCRIPTION/CONCLUSION: Slope-reducing HTO is an essential technique in the arsenal of complex ACL surgeons aiming to correct the detrimental effect of an increased PTS on ACL graft integrity in the setting of revision ACL-R.
在需要翻修前交叉韧带（ACL）重建手术的患者中，斜度矫正高位胫骨截骨术（HTO）因减轻胫骨后倾坡度（PTS）对移植物失败的影响而越来越受欢迎。生物力学和临床研究表明，PTS降低会导致移植物受力减少，患者预后良好，这使其成为复杂翻修ACL重建（ACL-R）中的一项重要技术。
对于ACL-R术后因PTS≥12°导致的复发性膝关节不稳定，可采用斜度矫正HTO进行治疗。
采用前内侧入路沿胫骨做3至4英寸切口，用牵开器保护暴露的髌腱。通过胫骨前肌筋膜切口暴露前侧间隙，随后抬起胫骨前肌并放置Hohmann牵开器。在胫骨结节内侧进行内侧副韧带（MCL）的骨膜下剥离。标记最终螺钉固定的位置，进行直的结节截骨术，不进行前移，使近端胫骨自由暴露。用两根克氏针标记截骨位置。在两侧使用Hohmann牵开器保护软组织结构，同时用摆动锯进行截骨。首选过矫正几度（1°-3°）。截骨完成后，保留1cm的后铰链。移除楔形骨块，在轻柔手动牵引下通过膝关节过伸进行复位。放置预塑形的低轮廓锁定钢板，近端3枚螺钉，远端3枚螺钉。在同期进行ACL-R时，螺钉应留出足够空间用于钻ACL胫骨隧道。
研究斜度矫正HTO与翻修ACL-R同期进行的效果时，报告显示胫骨前移和膝关节旋转不稳定减少，患者报告的结局改善，移植物失败风险降低。
描述/结论：对于旨在纠正PTS增加对翻修ACL-R中ACL移植物完整性的有害影响的复杂ACL外科医生来说，斜度降低HTO是其技术储备中的一项重要技术。
