One-stage Anterior Cruciate Ligament Reconstruction with Medial Open Wedge High Tibial Osteotomy - A Surgical...

Anterior cruciate ligament (ACL) deficiency in the presence of varus malalignment predisposes patients to accelerated medial compartment osteoarthritis (OA) and graft failure after isolated reconstruction. High tibial osteotomy (HTO) is an established method to realign the mechanical axis and offload the medial compartment. Performing ACL reconstruction (ACLR) and HTO in a single stage addresses both instability and malalignment simultaneously, minimizing the need for staged procedures and rehabilitation.

The procedure begins with diagnostic arthroscopy and femoral as well as tibial tunnel preparation before osteotomy, ensuring adequate knee hyperflexion. A hamstring graft is harvested and prepared, followed by a medial opening wedge HTO using a posteromedially placed osteotomy plate. Posterior screws are inserted first, leaving the anterior holes vacant until tibial tunnel identification. A metal dilator protects the tibial tunnel during anterior screw placement. The prepared graft is then passed, fixed with femoral and tibial cortical fixation or interference screws, and cancellous bone is packed into the tunnel to promote healing.

Single-stage ACLR with medial opening wedge HTO provides simultaneous correction of instability and malalignment in ACL-deficient varus knees. With careful surgical sequencing and technical modifications - especially early tunnel drilling and posteromedial plate placement - the procedure is safe, reproducible, and offers a practical solution for delaying OA progression while restoring knee stability.