Joint preservation procedures: osteotomies about the knee

Abstract

Osteotomies around the knee are an effective method for preserving the knee joint by correcting overall alignment. Although osteotomies have historically been used in treatment of knee pathology, they have recently regained a renewed interest as a treatment strategy for alignment correction, ligamentous stability, and cartilage preservation. Osteotomies are a powerful way to correct alignment in both the sagittal and coronal plane to preserve and/or protect the cartilage in the medial, lateral, and patellofemoral compartments of the knee and improve the ligamentous stability of the knee. Medial opening wedge high tibial osteotomy (MOW-HTO) and lateral closing wedge high tibial osteotomy (LCW-HTO) are commonly performed osteotomies for correcting varus malalignment, each with distinct indications, surgical techniques, and associated complications. Similarly, distal femoral osteotomy (DFO) plays a critical role in the correction of both varus and valgus malalignment, and may be particularly important in cases where a tibial osteotomy alone would lead to excessive joint line obliquity (JLO). In complex cases where single-level osteotomy does not provide optimal correction, double-level osteotomy may be necessary to achieve appropriate mechanical axis restoration while maintaining joint congruence. Beyond coronal plane corrections, increasing attention has been given to sagittal plane osteotomies for managing ligamentous instability, particularly anterior and posterior cruciate ligament (PCL) deficiencies. Modifying the posterior tibial slope (PTS) through anterior closing wedge or anterior opening wedge high tibial osteotomy can improve knee biomechanics and stability in both anterior cruciate ligament (ACL) and PCL-deficient patients. Additionally, tibial tubercle osteotomies (TTO) have emerged as an important surgical adjunct in the treatment of patellofemoral malalignment and cartilage preservation strategies. The goal of knee osteotomies is to offload the affected compartment, preserve and protect cartilage and menisci, and enhance ligamentous stability, thereby delaying the need for arthroplasty. Therefore, osteotomies represent an intriguing procedure for young and active patients. Recently, with the renewed interest in osteotomy procedures about the knee, studies have demonstrated that osteotomies continue to play a critical role in treatments for limb alignment and cartilage protection.

Keywords: Knee osteotomy; joint preservation; knee alignment.

Figure 1

Medial opening wedge high tibial osteotomy. This is a 41-year-old active patient with 12-degree varus alignment, who underwent a successful contralateral MOW-HTO in the past with significant improvement in her pain. She elected to proceed with a left MOW-HTO. Preoperative alignment (A), intraoperative fluoroscopy (B), postoperative radiographs (C) and final standing alignment (D). HTO, high tibial osteotomy; MOW, medial opening wedge.

Figure 2

Lateral opening wedge distal femoral osteotomy. Preoperative (A) and postoperative (B) standing alignment radiographs of a 21-year-old patient with significant valgus alignment as well as patellar instability, who underwent LOW-DFO for correction of valgus alignment. Intraoperative fluoroscopy demonstrates the planned osteotomy cuts with guidewires (C) and the use of an osteotomy (D) to complete the osteotomy. DFO, distal femoral osteotomy; LOW, lateral opening wedge.

Figure 3

Medial closing wedge distal femoral osteotomy. Preoperative (A) and postoperative (B) standing alignment radiographs of a 34-year-old patient with 6-degree valgus alignment, lateral femoral condyle cartilage defect, and lateral meniscus deficiency, who underwent an MCW-DFO, then subsequently underwent osteochondral allograft to the lateral femoral condyle and lateral meniscus transplant. Intraoperative fluoroscopy demonstrates the planned osteotomy with guidewires (C). Additionally, there was a noted lateral cortical hinge fracture that was fixed with a 4.5 mm screw (D). DFO, distal femoral osteotomy; MCW, medial closing wedge.

Figure 4

Anterior closing wedge high tibial osteotomy. Preoperative (A) and postoperative (B) lateral radiographs of a 20-year-old patient with a history of ACL reconstruction and subsequent graft retear with an increased PTS. Patient underwent a revision ACL reconstruction with ACW-HTO to reduce the PTS. Patient is now over 1 year postoperative and has returned to all activities and work. ACL, anterior cruciate ligament; ACW, anterior closing wedge; HTO, high tibial osteotomy; PTS, posterior tibial slope.