The current study by Won and colleagues concluded that patients undergoing revision ACL surgery have a greater incidence of significant varus alignment compared with patients undergoing primary ACL reconstruction. The authors also observed that this varus alignment was associated with meniscal pathology and degenerative changes of the knee. The report of varus alignment provides an interesting observation that goes a step beyond the findings of the Multi-center Anterior (C)ruciate Revision Study (MARS) , but leads to more questions than answers. The article does not tell us about the results of performing a high tibial osteotomy at the time of the revision ACL. It merely points out that these patients are potential candidates for such a procedure.
The strength of the manuscript is that it reminds us that varus malalignment is a potential variable to be mindful of. It also serves to warn surgeons they should be aware of possible failure of the graft, and continuing pain related to medial compartment degeneration. Won and colleagues’ attention to detail in establishing an effective protocol for the long-leg films is important because standing long-leg radiographs are fickle in terms of being able to demonstrate consistently the true amount of coronal plane alignment.