Single-Stage Revision Anterior Cruciate Ligament Reconstruction With Concomitant Lateral Extra-articular Tenodesis, High Tibial Osteotomy, and Medial Femoral Condyle Osteochondral Allograft Transplantation.

BACKGROUND

Combined ligamentous insufficiency, malalignment, and focal cartilage lesions in young, active patients represent a complex reconstructive challenge. Recent advances in patient-specific instrumentation, osteotomy planning, and biologic grafting techniques have enabled single-stage surgical solutions that address both instability and joint preservation.

INDICATIONS: The patient presented with grade 2B Lachman and rotational instability after a previous anterior cruciate ligament (ACL) reconstruction (ACLR). Indications for this combined approach included (1) ACL graft insufficiency with persistent rotational instability, treated with revision ACLR and lateral extra-articular tenodesis; (2) a 4 cm2 focal chondral defect of the trochlea, treated with osteochondral allograft transplantation (OCA); and (3) 6° varus malalignment in the setting of revision ACLR and cartilage restoration, treated with medial opening wedge high tibial osteotomy (HTO). A concomitant lateral meniscal root tear contributing to rotational instability was managed with root repair.

TECHNIQUE DESCRIPTION: Preoperative 3-dimensional computed tomography imaging with patient-specific instrumentation guided the osteotomy and tunnel trajectories to avoid interference between fixation constructs. After graft harvest and diagnostic arthroscopy, the femoral ACL tunnel was reamed, and the tibial tunnel was created through the patient-specific guide. The OCA was sized, harvested, and implanted flush to the trochlea. The medial opening wedge HTO (1° valgus overcorrection) was stabilized with a precontoured plate and tricortical bone wedges. The lateral extra-articular tenodesis graft, harvested as a 10 × 80 mm iliotibial band strip, was passed deep to the lateral collateral ligament and fixed at the proximal Kaplan's fiber region with a 4.75-mm polyetheretherketone suture anchor in 90° of flexion and neutral rotation.

RESULTS

Early follow-up demonstrated restored coronal alignment, well-positioned tunnels, and early osteotomy healing. The patient achieved full range of motion by 3 months and progressed with strengthening. The literature supports that combined ACLR, alignment correction, and cartilage restoration procedures restore stability and alignment while preserving native knee function, with 10-year studies reporting durable improvements in patient-reported outcomes.

DISCUSSION/

CONCLUSION

Single-stage revision ACL reconstruction with concomitant LET, medial opening wedge HTO, and osteochondral allograft transplantation is a feasible and effective strategy for young, active patients with combined ligamentous insufficiency, malalignment, and focal cartilage lesions, offering joint preservation with early functional recovery.

PATIENT CONSENT DISCLOSURE STATEMENT: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.