Combined Biplanar High Tibial Osteotomy, Anterior Cruciate Ligament Reconstruction, and Abrasion/Microfracture in Severe Medial Osteoarthritis of Unstable Varus Knees

Purpose To determine survivorship and functional results of medial open-wedge high tibial osteotomy (HTO) combined with anterior cruciate ligament reconstruction (ACLR) and a chondral resurfacing (CR) procedure (abrasion/microfracture) in patients with Kellgren-Lawrence grade 3 and 4 osteoarthritis with full-thickness cartilage defects, anterior cruciate ligament (ACL) insufficiency, and varus malalignment. Methods From October 2005 to March 2009, all combined HTO (fixation with angular stable internal fixator), ACLR, and CR procedures in knees with symptomatic medial osteoarthritis (Kellgren-Lawrence grade 3 and 4), ACL insufficiency, varus malalignment (>4°), and full-thickness large-area cartilage defects were prospectively surveyed with a minimum follow-up period of 5 years regarding survival (not requiring arthroplasty), functional outcome (subjective International Knee Documentation Committee [IKDC] score), and subjective satisfaction. Clinical evaluation (objective IKDC parameters and KT-1000 [MEDmetric, San Diego, CA] measurement), radiologic evaluation, and revision arthroscopy were performed between 1 and 2 years postoperatively. Results Twenty-three knees (mean age, 47.0 ± 5.8 years) were included. The rate of follow-up was 100% at 6.0 ± 0.8 years (range, 5.2 to 7.5 years), with no arthroplasty until then. The mean subjective IKDC score improved from 47.7 ± 11.1 to 72.8 ± 15.0 at 1 year, 70.9 ± 16.0 at 3 years, and 73.1 ± 16.4 at 5 years ( P < .001). Clinical examination and revision arthroscopy were performed in 22 cases (95.5%) at 1.3 ± 0.5 years (range, 1.0 to 2.0 years). Four ACL grafts (18.1%) were insufficient, and 2 grafts (9.1%) were stable but showed signs of degeneration. Good cartilage regeneration was seen in most cases, but no correlation with subjective IKDC score was apparent ( P = .528). Conclusions HTO in combination with ACLR and a CR procedure is effective in the treatment of severe medial osteoarthritis with concomitant ACL insufficiency and varus malalignment. The effect of the CR, as well as the reason for the considerable rate of graft insufficiency, remains unclear. Level of Evidence Level IV, therapeutic case series.