Slope-reducing tibial osteotomy yields better posterior horn healing performance of longitudinal and bucket-handle tears of medial meniscus in patients undergoing ACL reconstruction: a minimum 2-year follow-up study with second-look arthroscopy

PURPOSE: To assess the effect of additional slope-reducing tibial osteotomy (SRTO) on the healing rate of repaired meniscus posterior horn tears (MPHTs) in ACL-injured patients with steep PTS and excessive anterior tibial subluxation (ATS). METHODS: This retrospective study evaluated patients undergoing primary ACLR between 2016 and 2023 who met three inclusion criteria: PTS ≥ 15°, ATS≥6 mm, and repaired longitudinal and bucket-handle tears involving the meniscus posterior horn. Participants were stratified into an osteotomy group (ACLR + SRTO, n = 20) and a control group (ACLR alone, n = 48), with both cohorts maintaining ≥ 2-year follow-up. The primary endpoint compared meniscal horn healing rates between groups. Second, the associations between meniscal healing status and graft outcomes, as well as postoperative knee stability, were investigated. RESULTS: Both groups were comparable in terms of age, gender, side, BMI, PTS, graft diameter, time from injury to surgery, ATS, KT side-to-side differences, and pivot-shift grade (all P > 0.05). In the osteotomy group, 17 medial meniscus tears were identified (11 longitudinal and 6 bucket-handle tears). At the final follow-up, partial healing of medial MPHTs was achieved in 1 longitudinal tear, resulting in an overall healing rate of 94.1% (16/17). The control group presented with 34 meniscal tears (23 longitudinal + 11 bucket-handle tears). The final follow-up assessment revealed partial healing of medial MPHTs in 8 longitudinal and 2 bucket-handle tears, yielding a significantly lower overall healing rate of 70.6% (24/34) compared with the osteotomy group (P = 0.036). For lateral meniscus tears, the osteotomy group demonstrated partial healing of lateral MPHTs in 1 of 10 cases, compared with 5 of 33 cases in the control group, with no significant difference in overall healing rates between groups (90% vs. 84.8%, P = 0.680). In addition, partial healing of medial MPHTs was associated with residual graft laxity (50% vs. 16.7%, p = 0.045) compared to those with complete healing. CONCLUSION: For ACL-injured patients with steep PTS (≥ 15°) and excessive ATS (≥ 6 mm), the repaired medial MPHTs may benefit from the additional SRTO. In addition, incomplete healing of the posterior horn of the medial meniscus may be associated with residual ACL graft laxity. CLINICAL RELEVANCE: An additional slope-reducing tibial osteotomy may be indicated to facilitate medial meniscal healing in ACL injuries with excessive PTS and a concomitant posterior meniscal horn tear. LEVEL OF EVIDENCE: Cohort study III.