Higher precision and preservation of frontal plane alignment in slope-reducing infra-tubercle compared to retro-tubercle high tibial osteotomy.

Purpose: Slope-reducing high tibial osteotomies (SR-HTOs) correct posterior tibial slope (PTS) abnormalities in patients with anterior knee instability, as in cases of anterior cruciate ligament (ACL) deficiency. The SR-HTO techniques, including infra-tubercle and retro-tubercle approaches, provide distinct benefits: retro-tubercle techniques help preserve patellofemoral joint mechanics, while infra-tubercle techniques are effective in mitigating iatrogenic varus. However, there is limited comparative literature available. This study compares the PTS correction precision, frontal plane alignment changes, patellar height (PH) alterations and complications between both SR-HTO techniques.

Methods: A retrospective matched cohort study including 62 patients who underwent SR-HTO with ACL revision surgery between 2020 and 2023 was conducted. Of the 62 patients included, 40 (64.5%) were male and 22 (35.5%) were female. The mean follow-up period was 23.4 ± 7.7 months (range: 12-45 months). The cohort was subdivided into infra-tubercle (n = 29) and retro-tubercle (n = 33) groups. Preoperative and post-operative radiographic assessments included hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), proximal tibial slope (PTS) and PH indices. Functional outcomes were measured using the simple knee value (SKV) score. Complications such as hinge fractures, ACL re-rupture and hardware removal were recorded.

Results: Both techniques achieved similar mean slope correction with post-operative PTS in infra-tubercle: 9.2 ± 1.1° (range: 5-13.8°) versus retro-tubercle: 9.1 ± 1.3° (range: 5-14°). This has been reduced from a preoperative PTS in the infra-tubercle group of 14.2 ± 1.7° (range: 11.5-17°) versus retro-tubercle group: 14 ± 1.8° (range: 11-17.5°). Infra-tubercle osteotomy showed greater precision to pre-operative plans, with a deviation of 1.2 ± 1.1° (range: 0.0-3.6°) versus 1.8 ± 1.3° (range: 0.0-3.4°) in the retro-tubercle group (p = 0.02). Retro-tubercle SR-HTO induced greater coronal changes compared to infra-tubercle SR-HTO, ΔHKA: 1.4 ± 1.6° (range: 0-5°) versus 0.8 ± 0.8° (range: 0-2.8°) (p = 0.05); ΔMPTA: 1.6 ± 1.6° (range: 0-5.7°) versus 0.9 ± 0.7° (range: 0-2.8°) (p = 0.03). There was no intergroup difference in PH changes using either Caton-Deschamps or Schroter indices (p = 0.2). SKV improvement was greater in the infra-tubercle group compared to the retro-tubercle group, 28.7 ± 10.4 (range: 10.0-55.7) versus 20.7 ± 12.3 (range: -9.2 to 48.4) (p = 0.008). Complications were similar, with no hinge fractures and identical ACL re-rupture rates of 3.4%. Hardware removal was higher in the infra-tubercle group compared to the retro-tubercle group, 24.1% versus 9.1% (p = 0.2).

Conclusion: Infra-tubercle SR-HTO demonstrated greater correction accuracy and better preservation of frontal plane alignment and functional outcomes compared to the retro-tubercle technique, although the observed differences were modest. Both techniques maintained PH and exhibited comparable safety profiles. Infra-tubercle SR-HTO may offer a reliable alternative, particularly in ACL-deficient knees where precise slope correction is desired.

Level of evidence: Level III, retrospective comparative study.