Joint preservation procedures: osteotomies about the knee

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.