There are three clinical presentations with combined ACL laxity and medial compartment osteoarthritis. The first is the patient with primarily ACL laxity symptoms; that is, recurrent giving way and mild activity related pain. This is best treated with an ACL reconstruction alone. The second is the patient with more severe osteoarthritis and ACL
laxity. The symptoms are pain and giving way associated with a varus knee and medial compartment narrowing on the standing X-rays. This patient should be managed with a combined ACL reconstruction and tibial osteotomy done at the same sitting. It is acceptable to stage the osteotomy as the initial procedure, followed by the ligament reconstruction six months later. The third scenario is the patient with advanced medial compartment osteoarthritis and residual ACL laxity. The injury usually is long standing; the knee is in varus, but lacks extension. The patient at this point has pain, but not giving way. The best treatment is a tibial osteotomy. The closing wedge osteotomy of Coventry has been the standard, but the opening wedge osteotomy is becoming popular.
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