Journal: Arthroscopy Techniques
Article Title: Combined Anterior Opening-Wedge High Tibial Osteotomy and Tibial Tubercle Osteotomy with Posterior Cruciate Ligament Reconstruction
doi: 10.1016/j.eats.2021.12.014
Figure Lengend Snippet: This video demonstrates the technique for performing a combined tibial tubercle osteotomy (TTO), anterior opening wedge high tibial osteotomy (aOW-HTO), and posterior cruciate ligament reconstruction (PCL-R) for addressing posterior cruciate ligament (PCL) insufficiency in the setting of reduced posterior tibial slope in a right knee. This patient is a 16-year-old male who presented with right knee pain and instability 2 years after a bike injury. Further workup, including plain radiographs and magnetic resonance imaging, was notable for PCL insufficiency and reduced tibial slope. This patient was subsequently indicated for combined aOW-HTO, TTO, and PCL-R. The patient is positioned supine on a radiolucent table, and examination under anesthesia is performed. Diagnostic arthroscopy through the anterolateral portal of the knee is first performed to evaluate the status of the cruciate ligaments, menisci, and articular cartilage. A 10-cm anterior incision starting just proximal to the tibial tubercle is made, and medial and lateral skin flaps are raised. The patellar tendon is freed from the medial and lateral capsule, and a straight clamp is used to define the proximal aspect of the tibial tubercle. A line is marked 5 cm distal to the proximal aspect of the tibial tubercle, and a flat TTO is performed to yield an osteotomized tibial tubercle fragment that is ∼5 cm in length. Two guidewires are then inserted to template the planned HTO. The HTO is initially performed with an oscillating saw, and an osteotome is used to complete the osteotomy under fluoroscopic visualization to avoid inadvertent violation of the posterior tibial cortex. The osteotomy site is then opened to obtain the desired correction. The osteotomy gap is measured, and a wedge of iliac crest bone allograft is shaped and inserted into the osteotomy site, which is then further filled with further bone graft substitutes, including a preshaped block of calcium phosphate cement and demineralized bone matrix. Fixation of the tibial osteotomy is performed with medial and lateral low-profile titanium plates (Stryker, Kalamazoo, MI). The tibial tubercle fragment is then provisionally fixed to the proximal tibia, using fluoroscopy to confirm that patellar height has not been changed from preoperative patellar height. Once the tibial tubercle position is satisfactory, two headless compression screws (Arthrex, Naples, FL) are used for fixation of the tibial tubercle fragment. Arthroscopic all-inside posterior cruciate ligament reconstruction is then performed. The PCL remnant is debrided, and the posteromedial portal is established using modified Seldinger technique. The posterior capsule is elevated from the posterior tibia until the fibers of the popliteus are visualized. Using a tibial PCL guide (Arthrex), the surgeon advances the guide wire to the insertion of the PCL on the posterior tibia, ∼10 mm distal to the articular surface, and an 11-mm tibial socket is back-reamed. After a 1-cm incision is made over the medial femoral condyle, using a femoral PCL guide (Arthrex), a guidewire is advanced to the femoral origin of the PCL on the lateral aspect of the medial femoral condyle, and an 11-mm femoral socket is back-reamed. The femoral end of a previously prepared quadruple-stranded hamstring tendon allograft with preloaded suspensory buttons (Arthrex) is pulled into the femoral tunnel, and the suspensory button is flipped. The tibial end of the graft is then pulled into the tibial tunnel, and the second suspensory button is flipped. The knee is placed at 90° of flexion, an anterior drawer is applied, and the graft is subsequently tensioned on both the femoral and tibial sides.
Article Snippet: The authors’ preference is to use 4.5-mm cannulated fully threaded headless compression screws (Arthrex, Naples, FL).
Techniques:
