Chapter 63 Anterior Cruciate Ligament Reconstruction Combined with High-Tibial Osteotomy, Autologous Chondrocyte Implantation, Microfracture, Osteochondral, and/or Meniscal Allograft Transplantation

Introduction

Knees with chronic anterior cruciate ligament (ACL) tears often have degenerative changes. If these changes are severe, cartilage restorative procedures may be necessary in addition to ACL reconstruction (ACLR). The question in such cases is whether to perform the restorative procedures simultaneously with the ACLR. If they are not done simultaneously, the question becomes one of proper sequencing and the necessary time interval between procedures.

Individualization

Cases requiring combined procedures are inherently complicated. Some patients will need ACLR plus one other restorative procedure, but some patients may need a total of three or four such procedures. Decision-making can be helped by the application of certain principles, which will be discussed later. However, each patient’s individual characteristics should be carefully studied and weighed in decision-making. The patient’s pathology is most important, but work and life circumstances must be carefully considered to avoid disruption to the extent possible.

Surgeon Factors

The surgeon must also realistically weigh his or her own skill and experience. When in doubt, it is better to sequence procedures than to perform difficult procedures simultaneously with which the surgeon may have limited experience. Patients generally prefer simultaneity, but this should not be done if it will subject the patient to greater risk of failure.

Success Rates

In the literature and in our experience, success rates with appropriate combined procedures have been high. Table 63-1 summarizes the relevant literature. Surgery and aftercare must be meticulous. Reimbursement may not be commensurate with the amount of work performed. Not all surgeons will wish to perform these types of procedures. However, if the procedures are satisfactorily performed, and if the patients are carefully chosen, the results can be gratifying.

Table 63-1 Success Rates For Combined Procedures

Author	Year	Success Rate
ACLR with OATS
Klinger²⁰	2003	81% normal or nearly normal on IKDC
Bobic²¹	1996	10/12 patients had promising response at 2-year follow-up
ACLR with ACI
Amin⁸	2006	7/9 patients improved; 2/9 described no improvement
ACLR with MAT
Graf¹²	2004	1/8 patients had nearly normal results; 7/8 had abnormal or severely abnormal on IKDC scale
Sekiya¹¹	2003	86% normal or nearly normal on IKDC
Yoldas¹⁴	2003	19/20 reported normal or nearly normal on IKDC
Wirth¹⁵	2002	Recorded substantial improvement in both Lysholm and Tegner scores
Rath¹⁶	2001	Significantly reduced pain and increase function (SF-36)
Cameron¹⁷	1997	80% of patients who had ACLR + MAT had good-excellent results; 86% of those who had ACLR, MAT, and HTO had good to excellent results
ACLR with HTO
Williams²⁴	2003	Found statistically significant increases in Lysholm, HSS, Tegner score; 92% of patients were satisfied
Noyes²⁵	2000	Pain was reduced in 71% of knees; 71% of patients reported their knees as very good/normal or good
Stutz²⁶	1996	8/13 patients had normal or nearly normal subjective IKDC scores
Lattermann²⁹	1996	3/8 patients had pain even with light activity
Neuschwander²⁷	1993	4/5 patients had good or excellent result; one had fair
Noyes²⁵	1993	94% of patients reported significant improvement

ACI, Autologous chondrocyte implantation; ACLR, anterior cruciate ligament reconstruction; HSS, Hospital for Special Surgery; HTO, high-tibial osteotomy; IKDC, International Knee Documentation Committee; MAT, meniscal allograft transplantation; OATS, osteochondral autograft transfer system.

Patient Expectations

Patients must be counseled that success is by no means guaranteed with these combined procedures. It is important to discuss the possibility of failure and what the next steps would be. We believe that patients who do not comfortably accept the possibility of failure are best served by first seeing other surgeons to receive second opinions.

Restoration of Motion

The overriding concern in preoperative planning is the avoidance of loss of motion as a result of the surgical procedures. We will discuss the relative risk for each procedure in this regard. Above all, the knee must be flexible and noninflamed before surgery is performed. The reliability of the patient and access to appropriate physical therapy resources must also be factors in decision-making.

Anterior Cruciate Ligament Reconstruction and Microfracture

Microfracture has been shown to be an effective procedure for generating a fibrocartilaginous fill for full-thickness articular cartilage defects.¹^–³ It can easily be performed together with ACLR and should be performed simultaneously whenever possible to save the patient an extra and unnecessary anesthetic. The 6-week postoperative period of touchdown weight bearing that is required after microfracture (MF) does not adversely affect the ACLR. It is important only to make sure that good passive range of motion (ROM) is achieved. Decreased activity after ACLR has actually been associated with less tunnel widening in one study.⁴ For those who believe in aggressive strengthening immediately after ACLR, this regimen will seem restrictive. However, in the long term there should be no adverse effect. We have not found the addition of ACLR to adversely affect the expected good results after microfractures. There is no 2-year follow-up literature on ACLR with microfracture of which we are aware. However, our clinical experience has been favorable with lesions less than 2 cm. We have found larger lesions to not fare as well and in earlier years had to revise several microfractures to autologous chondrocyte implantations (ACI). Although the ultimate results in those cases were good, in recent years we have proceeded directly to ACI when encountering lesions greater than 2 cm.