Authors:
Evan P. Shoemaker B.A., Luke V. Tollefson B.S., Matthew T. Rasmussen M.D., Dustin R. Lee M.D., Robert F. LaPrade M.D., Ph.D
Abstract:
Revision anterior cruciate ligament reconstruction (ACLR) requires heightened levels of preoperative patient planning to evaluate for known risk factors of a primary ACLR graft failure. Risk factors include ≥12° of posterior tibial slope, coronal malalignment, nonanatomic femoral or tibial ACLR tunnel placement, and unaddressed ligament/meniscal injury. This technique describes an anterior closing wedge proximal tibial osteotomy, medial meniscus ramp repair, and bone grafting of the failed ACLR femoral and tibial tunnels. This is the first stage of a 2-stage revision ACLR aimed to address an increased posterior tibial slope that contributes to ACLR graft failure while concurrently bone grafting malpositioned failed ACLR tunnels and repairing an unstable medial meniscal tear to prevent further injury or exacerbation before the second-stage procedure.
Technique Video Credit: Evan P. Shoemaker B.A., Luke V. Tollefson B.S., Matthew T. Rasmussen M.D., Dustin R. Lee M.D., Robert F. LaPrade M.D., Ph.D. Published in: Arthroscopy Techniques, May 9, 2025
Known risk factors for anterior cruciate ligament (ACL) reconstruction (ACLR) graft failure include nonanatomic tunnel placement, residual instability from unrepaired ligament or meniscal injury, tunnel osteolysis/widening, increased posterior tibial slope (PTS) ≥12°, and coronal malalignment.1, 2, 3 Heightened level of complexity are presented to physicians when patients have ACLR failure with increased PTS in combination with unstable meniscal injuries.4
Medial meniscus ramp tears have been reported in 9.0% to 40.8% of ACL tears.5,6 It is well defined that unaddressed meniscal tears can lead to accelerated progression of osteoarthritis, increased translational/rotatory instability, and elevated compartment contact pressures.7 Whether a single- or multistage procedure, meniscus repair to salvage meniscal anatomy to prevent tear progression should be performed. A multistage procedure provides the opportunity to address sagittal malalignment with an anterior closing wedge proximal tibial osteotomy (ACW-PTO) and bone graft failed ACLR tunnels while repairing any unstable meniscus tears before revision ACLR to prevent irreparable progression.8 We describe an ACW-PTO, medial meniscus (MM) ramp repair, and ACL tunnel bone grafting in the setting of a planned 2-stage revision ACLR.
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