Pullout repair combined with double-plate fixation via inverted V-shaped high tibial osteotomy for medial meniscus posterior root tears with severe varus tibial deformity.

Abstract

Medial meniscus (MM) posterior root tears (PRTs) disrupt hoop stress transmission and accelerate the progression of medial compartment osteoarthritis. High tibial osteotomy (HTO) combined with transtibial pullout repair is indicated in selected patients with a high body mass index, severe varus malalignment, or high functional demands. Although medial open-wedge HTO (MOWHTO) is widely performed, correction angles exceeding approximately 12° may compromise mechanical stability and increase the risk of lateral hinge fracture and delayed union. In patients with predominantly tibial-based deformity and a predicted postoperative medial proximal tibial angle (MPTA) of less than 95°, double-level osteotomy is generally unnecessary; in such circumstances, a closing-wedge strategy is biomechanically appropriate. However, conventional lateral closing-wedge or hybrid closing-wedge HTO techniques reduce medial proximal tibial bone stock, leaving insufficient cortical bone to safely accommodate transtibial pullout repair for MMPRTs. Therefore, when HTO is performed in conjunction with MMPRT repair, preservation of adequate medial bone stock is essential. To our knowledge, no previous studies have described a technique specifically designed to address this structural requirement. This technical note describes a surgical technique combining transtibial pullout repair for MMPRTs with inverted V-shaped HTO (iV-HTO), a closing-wedge-based osteotomy that preserves medial cortical bone stock while permitting substantial angular correction. The medial approach required for pullout repair provides two additional advantages: independent tibial tunnel placement with reduced risk of interference from lateral plate screws second straightforward augmentation with an additional medial plate when indicated. The supplementary medial plate reinforces the weakened medial cortex, enhances construct stability, and may facilitate earlier weight-bearing while promoting reliable osseous union. The indications, surgical technique, technical considerations, and potential advantages of combining iV-HTO with transtibial pullout repair for MMPRTs in patients with severe tibial varus deformity are also presented.