The Role of Osteotomy in the Treatment of Posterior Cruciate Ligament (PCL) Injuries

A high tibial osteotomy (HTO) can provide relief of symptoms for the group of chronic posterior cruciate ligament (PCL)-deficient patients who have arthrosis so advanced that reconstruction is no longer recommended and are too young and active for knee arthroplasty. The ideal candidate for an osteotomy is young, active, without patellofemoral symptoms, and has full knee range of motion. Contraindications listed in this chapter include bone quality, loss of lateral meniscus, patellofemoral chondral loss, tobacco use, and obesity. Patient selection is key to success for a high tibial osteotomy. Helping patients set realistic expectations for outcomes is also an important part of preoperative planning. Radiographs are the standard for preoperative evaluation of mechanical alignment and osteotomy correction. Additional imaging with MRI helps to evaluate chondral injury and wear patterns, which is particularly important in patients with chronic PCL deficiency. Evaluation of the deformity in the coronal and sagittal planes is particularly important in patients who are PCL deficient due to the effect of tibial slope on knee kinematics. This chapter covers the salient points of patient selection, history, physical examination, radiographic evaluation, and surgical management of the chronic PCL-deficient patient when considering high tibial osteotomy.