Alignment Is Key for Complex Knee Repairs

By: Fernando Hernandez-Perez, M.D. and Pablo Eduardo Gelber, M.D., Ph.D.


High tibial osteotomy, despite its previous popularity and ability to provide pain relief as well as functional improvement with up to 90% survivorship at 15 years, has declined in some regions over the last two decades.1 Especially in the Western world, the use of osteotomies has been decreasing due to newer advancements in total and unicompartmental knee implant designs and surgical techniques.


The prevalence of this surgical procedure varies worldwide due to geographical, cultural and economic factors. These differences are influenced by the high range of motion preservation requirements in Asian cultures. Additionally, they are affected by limitations in technology access driven by varying regulations and costs across different countries. In Asia, as well as in other developing countries, these differences have restricted utilizing unicompartmental and total knee replacements in favor of knee osteotomies.


By contrast, osteotomies have remained popular in multiple Europe-based centers. However, they have shifted from being primarily a procedure for osteoarthritic knees to becoming an additional technique aimed at improving results in ligament, cartilage and meniscal treatments.


Consider the importance of maintaining proper knee alignment as similar to aligning the tires on a motor vehicle: It's logical to address tire alignment before they wear down instead of disregarding it and only replacing the tire when it's worn out.


Cumulative evidence indicates the superiority of unicompartmetal replacement when arthrosis is the primary concern. Additionally, there is a growing trend in the use of osteotomy to play a protective role, complementing complex knee reconstructions that include cartilage,2-4 meniscal,5,6 and ligament reconstructions. This is especially prominent in the context of multiligamentary and revision surgery settings.7-9


Patellar tracking and height modification used to be concerns in osteotomies. However, multiplanar stepped and oblique rotation osteotomies can address coronal, sagittal and rotational alignment simultaneously. This multiplanar alignment correction allows for the independent adjustment of the tibial tubercle using distal biplanar and free tubercle fragment osteotomies, acting as a biological bridge plate. This, in turn, facilitates the improvement of patella height and tracking while simultaneously addressing coronal and sagittal alignment.

The use of specialized retractors, including some radiolucent ones, improves safety and reliability. Additionally, the use of multiple alignment control pins and specialized guides further contributes to the enhancement of these procedures. Improvements in preoperative planning and utilizing personalized instrumentation as well as guides further allow for more accurate corrections and fixations than ever before.


In conjunction with these advanced osteotomy techniques, there have been significant modifications in implant design, resulting in more anatomically and mechanically superior implants that facilitate concurrent procedures like tunnel drilling for ligament or meniscal interventions. Looking ahead, we may not be too far from the adoption of augmented reality and robotic assistance to enhance our technique and safety when performing these procedures.


We might soon witness a "back to the future" phenomenon when it comes to knee osteotomies, as technology continues to evolve and improve. This idea is reminiscent of the famous line: "I Guess You Guys Aren't Ready for That Yet. But Your Kids Are Gonna Love It.”14



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  12. LaPrade, R.F., Oro, F.B., Ziegler, C.G., Wijdicks, C.A., Walsh, M.P. “Patellar Height and Tibial Slope After Opening-Wedge Proximal Tibial Osteotomy: A Prospective Study.” The American Journal of Sports Medicine. 2010; 38:160-170.
  13. Song, E.K., Seon, J.K., Park, S.J., Jeong, M.S. “The Complications of High Tibial Osteotomy: Closing- Versus Opening-Wedge Methods.” The Journal of Bone and Joint Surgery – British Volume. 2010;92:1245-1252.
  14. Back to the Future. Directed by Robert Zemeckis. Performances by Michael J. Fox, Universal Pictures/ Amblin Entertainment, 1985
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