Treating the Double and Triple Varus Unstable Knee
Abstract & commentary
Synopsis: High tibia osteotomy and a delayed ACL reconstruction were effective in treating the double and triple varus knee.
Source: Noyes FR, et al. High tibia osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med 2000;28:282-296.
This article reports a consecutive series of 41 patients treated with high tibial osteotomy and ACL reconstruction for the varus angulated ACL deficient knee. To be included in the study, patients had to have ACL deficiency treated by bone tendon bone reconstruction, varus malalignment, and lateral ligament insufficiency. Patients were excluded if they had any other ligament instabilities. Twenty-three knees had a double varus deformity (varus and lateral ligament insufficiency), and 18 had a triple varus deformity (varus, lateral ligament insufficiency plus recurvatum and external tibial rotation). Prior to referral to Noyes and colleagues, 15 patients had 19 ACL reconstructions that failed, and 73% of the patients had medial meniscectomies.
Patients were evaluated by the Cincinnati Knee Rating Score, KT 2000, long leg alignment films and a posterolateral knee exam. A computer was used to assess gait and a treatment algorithm was followed to determine the diagnosis and surgical management.
In most, the high tibia osteotomy was performed initially to treat the varus deformity and was followed in approximately eight months by ACL reconstruction (20 allografts, 21 autografts). In three knees, the ACL reconstruction and osteotomy were performed concurrently. Posterolateal reconstructions were performed in 18 knees, and medial meniscal allografts were transplanted in six knees.
Statistically significant improvement in pain, swelling, giving way, activities of daily living, and sport function were recorded. Only 29 of 41 patients reported the knee function as good or better.
Surgical correction on the double varus knees resulted in an average of 2 mm abnormal opening for the lateral structures. Postoperatively, the triple varus knees had reduction of the hyperextension to zero degrees except in two cases, which remained in hyperextension. Eighty percent of the long leg alignment films demonstrated acceptable alignment. Fourteen knees had revision surgeries performed, including two revision oseotomies, two loss of osteotomy fixations, seven revisions of the ACL reconstruction, and three resections of the meniscus allografts.
Comment by James R. Slauterbeck, MD
Double and triple varus knees are challenging cases for the orththopedic surgeon. The combination of articular surface loss, instability, and malalignment require osteotomies and soft tissue reconstruction to obtain appropriate stability and function without pain. A treatment algorithm is presented to help organize the approach for these challenging cases.
The patients were mostly satisfied with 70% reporting reduction of pain, 85% reporting stable knees, and 66% returning to light activity. The postoperative alignment was acceptable in 80% at early follow-up. Postoperative complications like arthrofibrosis and infections did not occur; however, seven ACL and two osteotomy revisions were performed.
This article is important because it defines Noyes et al’s experience in the treatment of these complex injuries. If patients have a varus deformity and are unstable, then osteotomy followed by a delayed ACL reconstruction with bone patella tendon bone autograft is a good choice. If lateral ligaments are attenuated, expect adaptive shortening and proceed with the above plan. If posterolateral structures are loose, then perform HTO followed by a delayed ACL and posterolateral reconstruction with autograft or allograft. Some other warnings were reported: Be careful of performing concomitant meniscus transplant because they failed in this series. Also, be careful of allograft bone patella tendon bone tissue because there was a higher revision rate.
In my opinion, it is important to first treat the bone mal-alignment so that the soft tissue reconstructions are not exposed to excessive stress. I find that many patients are happy after the osteotomy is performed and do not request further ligament surgery. Additionally, the rehab for an osteotomy, meniscus transplant, and soft tissue ligament reconstructions are all different. For example, successful rehabilitation for an ACL reconstruction is much more aggressive than the other procedures and probably should be done at a separate time after an osteotomy is healed.
In summary, a staged reconstruction first addressing the bone malalignment and secondly addressing the instabilities was effective at decreasing pain and increasing function. Hopefully, as we get better at meniscus repair or with meniscus transplants, the need for this complex surgery will lessen and the double and triple varus knee will become a problem of the past.
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