Background: The presence of varus deformity in anterior cruciate ligament (ACL)-deficient knees can be a source of persistent knee pain owing to medial compartment overload. This deformity may threaten the outcome of ACL reconstruction because of increased tension on the graft. Methods: In the period between June 2006 to January 2013, 12 patients with ACL deficiency and genu varus were treated by anatomical single bundle ACL reconstruction and open medial wedge high tibial osteotomy. The selected patients had manifestations of ACL deficiency in association with medial joint line pain with or without lateral thrust. Results: Prospective evaluation using the International Knee Documentation Committee (IKDC) score was performed. The mean follow-up period was 56 months (range, 26e74 months). This technique achieved knee stability and realignment to normal values. The IKDC score has significantly improved from 37 (pre-operation) to 78 (post-operation) (p < 0.05). Conclusion: Thecombined procedure ofACL reconstruction and high tibial osteotomy restored knee stability and reduced pain over the medial compartment. Although the combined procedure has a longer period of rehabilitation than an isolated ACL reconstruction, the elimination of lateral thrust and preservation of articular cartilage of the medial compartment are of paramount importance to the future of these knees.