Abstract
Purpose
To report outcomes of first revision anterior cruciate ligament reconstruction (ACLR) with tibial deflexion osteotomy (TDO) in patients with posterior tibial slope (PTS) >10° at >2 years.
Methods
The authors studied outcomes of a consecutive series of 16 patients that underwent first revision ACLR with TDO, including Lysholm score, IKDC subjective and objective scores, Lachman test, PTS, and signs of osteoarthritis. One woman was excluded because of early signs of knee arthritis, as the first revision ACLR took place 27 years following the primary ACLR. This left a final cohort of 15 patients assessed at minimum follow-up of 2 years.
Results
The final cohort comprised 14 men and 1 woman aged 25.3 ± 6.6 years (range 16–39) at first revision ACLR. At final follow-up of 4.4 ± 1.5 years (range, 2–7), PTS was corrected from 12.5 ± 1.8° (range 8–15°) to 1.9 ± 3.6° (range – 4 to 8°), and none of the knees had radiographic signs of osteoarthritis. Lysholm score was 83.8±12.5, IKDC subjective score was 80.3±16.2, and IKDC objective score was A in 5 (33%), and B in 10 (67%). The net improvement exceeded the minimal clinically important difference (MCID) in 93% of patients for the IKDC subjective score and in 80% of patients for the Lysholm score. None of the knees had any retears, and only one required a reoperation to re-suture a medial meniscal tear due to trauma.
Conclusion
At 2-7 years following revision ACLR combined with TDO, net improvement exceeded the MCID in 93% of patients for IKDC subjective score and in 80% of patients for Lysholm score, with no retears or major complications. These results suggest that TDO is a safe technique to protect the ACL graft and might be considered as of first revision ACLR to correct excessive PTS.
Level of evidence
Level IV
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs00167-023-07493-x/MediaObjects/167_2023_7493_Fig1_HTML.png)
Similar content being viewed by others
Data availability
Data is available upon reasonable request.
References
Akoto R, Alm L, Drenck TC, Frings J, Krause M, Frosch KH (2020) Slope-correction osteotomy with lateral extra-articular tenodesis and revision anterior cruciate ligament reconstruction is highly effective in treating high-grade anterior knee laxity. Am J Sports Med 48(14):3478–3485
Bien DP (2011) Rationale and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes. J Strength Cond Res 25(1):271–285
Christensen JJ, Krych AJ, Engasser WM, Vanhees MK, Collins MS, Dahm DL (2015) Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Am J Sports Med 43(10):2510–2514
Cicchetti DV, Volkmar F, Sparrow SS, Cohen D, Fermanian J, Rourke BP (1992) Assessing the reliability of clinical scales when the data have both nominal and ordinal features: proposed guidelines for neuropsychological assessments. J Clin Exp Neuropsychol 14(5):673–686
Dejour D, Khun A, Dejour H (1998) Osteotomie tibiale de déflexion et laxité chronique antérieure à propos de 22 cas. Rev Chir Orthop. 84:28–29
Dejour D, La Barbera G, Pasqualotto S, Valoroso M, Nover L, Reynolds R, Saffarini M (2017) Sagittal plane corrections around the knee. J Knee Surg 30(8):736–745
Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G (2019) Preoperative laxity in ACL-deficient knees increases with posterior tibial slope and medial meniscal tears. Knee Surg Sports Traumatol Arthrosc 27(2):564–572
Dejour D, Saffarini M, Demey G, Baverel L (2015) Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc 23(10):2846–2852
Dejour H, Bonnin M (1994) Tibial translation after anterior cruciate ligament rupture Two radiological tests compared. J Bone Joint Surg Br. 76(5):745–749
Ebben WP, Fauth ML, Petushek EJ, Garceau LR, Hsu BE, Lutsch BN, Feldmann CR (2010) Gender-based analysis of hamstring and quadriceps muscle activation during jump landings and cutting. J Strength Cond Res 24(2):408–415
Engler ID, Salzler MJ, Wall AJ, Johnson WR, Makani A, Shields MV, Gill TJ (2020) Patient-reported outcomes after multiple-revision ACL reconstruction: good but not great. Arthrosc Sports Med Rehabil 2(5):e539–e546
Feucht MJ, Mauro CS, Brucker PU, Imhoff AB, Hinterwimmer S (2013) The role of the tibial slope in sustaining and treating anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 21(1):134–145
Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD (2004) Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med 32(2):376–382
Griffith TB, Allen BJ, Levy BA, Stuart MJ, Dahm DL (2013) Outcomes of repeat revision anterior cruciate ligament reconstruction. Am J Sports Med 41(6):1296–1301
Gupta A, Tejpal T, Shanmugaraj A, Horner NS, Simunovic N, Duong A, Ayeni OR (2019) Surgical techniques, outcomes, indications, and complications of simultaneous high tibial osteotomy and anterior cruciate ligament revision surgery: a systematic review. HSS J 15(2):176–184
Gwinner C, Janosec M, Wierer G, Wagner M, Weiler A (2021) Graft survivorship after anterior cruciate ligament reconstruction based on tibial slope. Am J Sports Med 49(14):3802–3808
Imhoff FB, Comer B, Obopilwe E, Beitzel K, Arciero RA, Mehl JT (2021) Effect of slope and varus correction high tibial osteotomy in the ACL-deficient and ACL-reconstructed knee on kinematics and ACL graft force: a biomechanical analysis. Am J Sports Med 49(2):410–416
Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502
Malahias MA, Shahpari O, Kaseta MK (2018) The clinical outcome of one-stage high tibial osteotomy and anterior cruciate ligament reconstruction. A current concept systematic and comprehensive review. Arch Bone Jt Surg 6(3):161–168
Marouane H, Shirazi-Adl A, Adouni M, Hashemi J (2014) Steeper posterior tibial slope markedly increases ACL force in both active gait and passive knee joint under compression. J Biomech 47(6):1353–1359
Myer GD, Ford KR, Khoury J, Succop P, Hewett TE (2011) Biomechanics laboratory-based prediction algorithm to identify female athletes with high knee loads that increase risk of ACL injury. Br J Sports Med 45(4):245–252
Norman GR, Sloan JA, Wyrwich KW (2003) Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care 41(5):582–592
Okutan AE, Kalkışım M, Gürün E, Ayas MS, Aynacı O (2022) Tibial slope, remnant preservation, and graft size are the most important factors affecting graft healing after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 30(5):1584–1593
Rozinthe A, van Rooij F, Demey G, Saffarini M, Dejour D (2022) Tibial slope correction combined with second revision ACLR grants good clinical outcomes and prevents graft rupture at 7–15-year follow-up. Knee Surg Sports Traumatol Arthrosc 30(7):2336–2341
Salmon LJ, Heath E, Akrawi H, Roe JP, Linklater J, Pinczewski LA (2018) 20-year outcomes of anterior cruciate ligament reconstruction with hamstring tendon autograft: the catastrophic effect of age and posterior tibial slope. Am J Sports Med 46(3):531–543
Sonnery-Cottet B, Mogos S, Thaunat M, Archbold P, Fayard JM, Freychet B, Clechet J, Chambat P (2014) Proximal tibial anterior closing wedge osteotomy in repeat revision of anterior cruciate ligament reconstruction. Am J Sports Med 42(8):1873–1880
Stride D, Wang J, Horner NS, Alolabi B, Khanna V, Khan M (2019) Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27(4):1320–1331
Tanaka T, Gale T, Nishida K, Xu C, Fu F, Anderst W (2023) Posterior tibial slope and meniscal slope correlate with in vivo tibial internal rotation during running and drop jump. Knee Surg Sports Traumatol Arthrosc 31(6):2366–2373
van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF (2022) Meniscal tears, posterolateral and posteromedial corner injuries, increased coronal plane, and increased sagittal plane tibial slope all influence anterior cruciate ligament-related knee kinematics and increase forces on the native and reconstructed anterior cruciate ligament: a systematic review of cadaveric studies. Arthroscopy 38(5):1664-1688.e1661
Waiwaiole A, Gurbani A, Motamedi K, Seeger L, Sim MS, Nwajuaku P, Hame SL (2016) Relationship of ACL injury and posterior tibial slope with patient age, sex, and race. Orthop J Sports Med 4(11):2325967116672852
Winkler PW, Wagala NN, Hughes JD, Lesniak BP, Musahl V (2022) A high tibial slope, allograft use, and poor patient-reported outcome scores are associated with multiple ACL graft failures. Knee Surg Sports Traumatol Arthrosc 30(1):139–148
Wyrwich KW, Bullinger M, Aaronson N, Hays RD, Patrick DL, Symonds T (2005) Estimating clinically significant differences in quality of life outcomes. Qual Life Res 14(2):285–295
Acknowledgments
Collaborators of ReSurg: Floris van Rooij, Mo Saffarini, ReSurg SA, Rue Saint Jean 22, 1260, Nyon, Switzerland.
Funding
The authors are grateful to GCS Ramsay Santé pour l’Enseignement et la Recherche for funding statistical analysis and manuscript preparation.
Author information
Authors and Affiliations
Consortia
Ethics declarations
Conflict of interest
DD reports personal fees from SBM, outside the submitted work; AR, GD, FVR, and MS have nothing to disclose.
Ethical approval
All patients provided informed consent for the use of their data for research, and the study was approved by the ethical board in advance (Ramsay Santé, IRB approval number: COS-RGDS-2021-03-007-DEJOUR-D).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
The members of the ReSurg collaborator names are presented in the acknowledgement section.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Dejour, D., Rozinthe, A., Demey, G. et al. First revision ACL reconstruction combined with tibial deflexion osteotomy improves clinical scores at 2 to 7 years follow-up. Knee Surg Sports Traumatol Arthrosc 31, 4467–4473 (2023). https://doi.org/10.1007/s00167-023-07493-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-023-07493-x