CORR Insights®: Coronal Limb Alignment and Indications for High Tibial Osteotomy in Patients Undergoing Revision ACL Reconstruction

Where Are We Now?The current study by Won and colleagues concluded thatpatients undergoing revision ACL surgery have a greaterincidence of significant varus alignment compared withpatients undergoing primary ACL reconstruction. Theauthors also observed that this varus alignment was asso-ciated with meniscal pathology and degenerative changesof the knee. The report of varus alignment provides aninteresting observation that goes a step beyond the findingsof the Multi-center Anterior (C)ruciate Revision Study(MARS) [1], but leads to more questions than answers. Thearticle does not tell us about the results of performing ahigh tibial osteotomy at the time of the revision ACL. Itmerely points out that these patients are potential candi-dates for such a procedure.The strength of the manuscript is that it reminds us thatvarus malalignment is a potential variable to be mindful of.It also serves to warn surgeons they should be aware ofpossible failure of the graft, and continuing pain related tomedial compartment degeneration. Won and colleagues’attention to detail in establishing an effective protocol forthe long-leg films is important because standing long-legradiographs are fickle in terms of being able to demonstrateconsistently the true amount of coronal plane alignment.Where Do We Need to Go?Kimandcolleagues[3]reportedthatasidefromextremecaseswith varus thrust (without medial compartment arthritis) thestability and functional scores were not adversely affected byprimary varus alignment. Kim and colleagues [3]alsoreported that aside from extreme cases where varus thrust isnoted, (in addition to the post meniscectomy changes) theradiographic features of unicompartmental osteoarthritis areinsufficient to be associated with graft failure.Another MARS study [2] indicated that a significantnumber of revision surgeries were related to technicaldifficulties in graft tunnel placement in the primary pro-cedure. This raises a number of questions. Was thedegenerative process and progressive varus at fault incausing the ligament failure in the other revision surgeriesnot related to graft tunnel placement? Which patients needproximal tibial osteotomies at the time of revision ACLsurgery? Should a high tibial osteotomy be performed toavoid postsurgical medial joint line pain? Will concomitantrealignment increase the chance of establishing stability orwould staging the two procedures not only eliminate the