Combined ACL reconstruction & proximal tibial osteotomy

Combined proximal tibial osteotomy and ACL reconstruction is indicated for patients with chronic ACL deficiency and medial meniscectomy/cartilage loss and varus mechanical alignment. This can be a chronic primary ACL injury with previous medial meniscectomy or a revision setting in a patient with medial cartilage loss and failed primary reconstruction. Open wedge medial proximal tibial osteotomy is the preferred technique since it preserves tibial bone stock and does not require a fibular osteotomy. Increasing the tibial slope, a common problem in open wedge osteotomies, should be avoided since this would increase detrimental loads on the ACL graft. The goal is to achieve a neutral mechanical axis and valgus overcorrection should also be avoided in younger patients. The sequence of surgery is
1. Hamstring tendon graft harvest and preparation
2. Arthroscopic creation of the femoral tunnel and additional intra- articular procedures (meniscal & chondral)
3. Open wedge tibial osteotomy and fixation, leaving adequate space for the tibial tunnel.
4. Creation of the tibial tunnel
5. ACL graft passage and fixation