Concurrent High Tibial Osteotomy, Anterior Cruciate Ligament Reconstruction, and Medial Meniscus Posterior Root Repair.

Medial meniscus posterior root tears and anterior cruciate ligament (ACL) injuries disrupt knee biomechanics and accelerate joint degeneration, particularly in the presence of varus malalignment. This technical note describes a combined surgical approach that integrates medial meniscus posterior root repair, ACL reconstruction, and high tibial osteotomy (HTO) to restore joint stability, optimize load distribution, and prevent osteoarthritis progression. The procedure is performed arthroscopically using anteromedial and anterolateral portals. Meniscal root and ACL footprints are prepared, and sutures are passed using a loop-stitch technique. A biplanar high tibial osteotomy is then performed distal to the guide pins to correct varus alignment, with plate fixation positioned posteriorly and distally for optimal stability. The meniscal root tunnel is drilled at a 45° angle, followed by ACL tunnel placement and graft fixation using interference screws and a suspensory button system. This combined approach enables simultaneous restoration of meniscal function, knee stability, and mechanical alignment, potentially improving long-term outcomes compared with isolated procedures.