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Review
. 2025 Apr;18(4):149-159.
doi: 10.1007/s12178-025-09946-x. Epub 2025 Feb 21.

The Role of Alignment in Treating Meniscus Pathology

Adam V Daniel  1 , Amelia J Weingart  1 , Lindsay E Barrera  1 , Andrew D Carbone  1 , Abhishek S Kannan  1 , Bruce A Levy  2   3
Affiliations
Review

The Role of Alignment in Treating Meniscus Pathology

Adam V Daniel et al. Curr Rev Musculoskelet Med. 2025 Apr.

Abstract

Purpose of review: Limb alignment correction about the knee joint is crucial for the protection of the meniscus, particularly in the setting of meniscal root repairs and meniscal allograft transplantation. Distal femoral osteotomies and high tibial osteotomies have been described to restore the anatomic alignment to aid in meniscal preservation. This article provides a review of knee alignment and biomechanics, various surgical interventions to correct knee malalignment, and the effect of malalignment on the treatment of meniscal pathology.

Recent findings: Both distal femoral and high tibial corrective osteotomies have been shown to slow the progression of osteoarthritis in the postoperative period. Moreover, corrective osteotomies have resulted in high patient satisfaction and good survival rates at mid- to long-term follow-up in patients with prior varus/valgus malalignment. Ongoing research is aimed to determine the best utilization for concomitant osteotomies in the setting and treatment of meniscal pathology with hopes of decreasing the progression of early-onset osteoarthritis, and ultimately, the conversion to total knee arthroplasty. Neutral alignment at the level of the knee joint results in optimal force distributions. Corrective valgus and varus osteotomies aim to restore neutral alignment with the goal of ligamentous and meniscal preservation, ideally slowing osteoarthritis progression.

Keywords: Distal femoral osteotomy; High tibial osteotomy; Meniscal allograft transplant; Root repair; Valgus malalignment; Varus malalignment; meniscus; distal femoral osteotomy; high tibial osteotomy; varus malalignment; valgus malalignment; osteoarthritis..

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Conflict of interest statement

Declarations. Human and Animal Rights and Informed Consent: This article does not contain any studies with human or animal subjects performed by any of the authors. Competing Interest: Bruce A. Levy has received consulting fees from Arthrex; nonconsulting fees from Arthrex and Smith+Nephew; royalties from Arthrex; and has stock/stock options in COVR Medical.Andrew D. Carbone has received funding grants from Arthrex and Medical Device Business Services Inc; speaking and lecture fees from Arthrex, Smith+Nephew, Medwest Associates Inc, Micromed Inc, and Saxum Surgical Inc.Abhishek S. Kannan has received consulting fees from Linvatec Corporation; and speaking and lecture fees from Arthrex.

Figures

Fig. 1
Fig. 1
Standing AP radiograph of bilateral knees demonstrating medial joint space narrowing of the right knee (yellow arrow) compared to the left. Suture buttons from a previous ACL procedure noted on both the femur and tibia. The femoral tunnel is noted to be 10.9-mm wide, and the tibial tunnel is noted to be 11.9-mm wide
Fig. 2
Fig. 2
Magnetic resonance imaging of the right knee demonstrating: (A) medial compartment subchondral edema of the medial tibial plateau with normal lateral compartment cartilage on the coronal, (B) medial compartment subchondral edema, and (C) medial meniscal deficiency on the sagittal views
Fig. 3
Fig. 3
(A) Preoperative standing long films demonstrating a slight varus alignment (red line) of the right leg compared to neutral alignment (yellow line) of the left leg. (B) Postoperative long-leg radiographs after HTO demonstrating slight valgus alignment (red line) of the right leg compared to neutral alignment (yellow line) of the left leg
Fig. 4
Fig. 4
The medial meniscus allograft. (A) overhead view of the meniscal allograft with a posterior bone plug (P). (B) Arthroscopic view through the anterolateral portal of the medial compartment of the right knee posterior root fixation and (C) meniscal graft body fixation
Fig. 5
Fig. 5
Standing long-films demonstrating 6° of varus alignment of the left leg compared to neutral alignment of the right leg
Fig. 6
Fig. 6
Intraoperative fluoroscopy of the left knee following an opening wedge high tibial osteotomy
Fig. 7
Fig. 7
Arthroscopic view through the anterolateral portal of the medial compartment of the left knee demonstrating (A) a posterior root tear and (B) final fixation following repair using the transtibial pullout method
Fig. 8
Fig. 8
Magnetic resonance imaging of the right knee demonstrated disruption to the (A) lateral meniscus and anterior cruciate ligament with subchondral edema noted of the lateral tibial plateau and lateral femoral condyle on the coronal view, and a (B) 23-mm chondral injury noted on the sagittal view
Fig. 9
Fig. 9
(A) Long-leg films demonstrating valgus malalignment (red line) of the right leg compared to a slight varus (yellow line) left leg. (B) Postoperative long-leg films following an 8° varus-producing closing wedge distal femoral osteotomy
Fig. 10
Fig. 10
Overhead view of the lateral meniscal allograft prior to transplantation
Fig. 11
Fig. 11
Arthroscopic view through the (A) anteromedial portal demonstrating lateral meniscal deficiency. (B) Arthroscopic view through the anterolateral portal demonstrating a lateral meniscal allograft transplant following fixation
Fig. 12
Fig. 12
Intraoperative photograph demonstrating matrix-induced autologous chondrocyte implantation of the lateral femoral condyle
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