Slope Correcting Anterior Closing Wedge Tibial Osteotomy Using Patient-Specific Instrumentation in Setting of Multiple Previous Revision ACL Reconstructions

Background: Graft failure after anterior cruciate ligament (ACL) reconstruction (ACLR) is a rare but devastating complication that is often multifactorial. Increased posterior tibial slope (PTS) is a known risk factor for graft failure after ACLR. Anterior closing wedge high tibial osteotomy (ACW-HTO) has been shown to reliably correct PTS and improve knee stability. Indications: In patients with failed ACLR and PTS ≥12°, ACW-HTO for posterior slope correction may be indicated. Technique Description: The presented technique demonstrates an ACW-HTO in a female Division I athlete with 2 previous ACLRs and recurrent graft failure. Patient-specific instrumentation (PSI) planning software is used to develop a 3-dimensional-printed cutting guide for HTO and a proximal tibia plate guide to aid in precise slope correction. An ACW-HTO is performed from the anteromedial aspect of the proximal tibia utilizing the premade cutting guide and a posterior hinge pin. A 6-hole patient-specific proximal tibia plate is then applied, taking care to avoid potential future ACLR tibial tunnel trajectory. Results: Previous studies have demonstrated a low graft failure rate, improved patient outcomes, and highly variable return-to-sport rates after slope-corrected osteotomy in the setting of ACL insufficiency. Improved posterior tibial slope decreases rates of subsequent ACL graft failure and, in some cases, may obviate the need for revision ACLR because of subjective improvement in knee stability. Discussion/Conclusion: This surgical technique video demonstrates a reliable, reproducible method of PTS correction in the setting of multiple failed ACLRs with recurrent graft failure. Technique modifications and the addition of concomitant procedures to ACLR are increasing in popularity to reduce rerupture rates and improve patient outcomes. ACW-HTO for slope correction is a powerful tool that should be considered in select patients with ACL injuries and increased posterior tibial slope. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.