Knee Malalignment Surgical Treatment

Osteotomy is considered for the active patient whose pain is localized to the overloaded compartment, whose cartilage damage is confined to that compartment, and who has good motion and a stable, otherwise healthy knee. It is particularly valuable for patients who are young for a partial or total knee replacement, since it preserves the natural joint and allows a return to higher levels of activity.

Osteotomy is also frequently performed alongside cartilage restoration, meniscal transplantation, or ligament reconstruction, where leaving the malalignment uncorrected would place the other procedures at risk.

Patients with advanced arthritis in multiple compartments, inflammatory arthritis, or significant stiffness are generally better served by other options, such as a partial or total knee replacement. Nicotine use significantly impairs bone healing, and patients are asked to stop all nicotine products before surgery.

Every osteotomy is planned in advance using digital templating on full-length standing x-rays, so the exact correction is determined before the operation begins. The goal is to move the weight-bearing line to a precise target, enough to unload the damaged compartment without overloading the healthy one.

Dr. Rynecki Baker frequently uses patient-specific instrumentation, in which cutting guides and plates are custom-made from the patient’s own imaging. These guides direct the bone cut and correction during surgery, increasing precision and reliably achieving the planned alignment.

Both bowlegged and knock-kneed knees can be corrected through either the tibia or the femur. The choice of bone depends on where the deformity originates, since correcting the bone that is actually misshapen keeps the joint line level. Within each bone, the correction can be made with an opening wedge, in which the bone is cut and gently spread to the planned angle, or a closing wedge, in which a small wedge of bone is removed and the edges are brought together. The cut can be made from the inner (medial) or outer (lateral) side, and the combination of location and wedge type determines the direction of the correction. Dr. Rynecki Baker weighs the size of the correction, bone quality, and any associated procedures to individualize this decision to you. The correction is held with a plate and screws, and bone graft may be used to fill the gap in an opening wedge osteotomy.

High Tibial Osteotomy

High tibial osteotomy is performed on the tibia just below the knee. It is most commonly used to correct a bowlegged knee and unload the medial compartment, either by opening a wedge from the inner side or by closing a wedge from the outer side. When a knock-kneed deformity originates in the tibia, the approach is reversed, closing a wedge from the inner side or opening one from the outer side to unload the lateral compartment.

Distal Femoral Osteotomy

Distal femoral osteotomy is performed on the femur just above the knee. It is most commonly used to correct a knock-kneed knee and unload the lateral compartment, either by opening a wedge from the outer side or by closing a wedge from the inner side. When a bowlegged deformity originates in the femur, the approach is reversed, closing a wedge from the outer side or opening one from the inner side to unload the medial compartment.

Slope-Correcting Osteotomy

Slope-correcting osteotomy addresses the front-to-back tilt of the tibia rather than side-to-side alignment. Excessive posterior tibial slope, in which the top of the tibia is too steep, places continuous strain on the ACL and on an ACL graft. Correcting it by removing a small wedge of bone from the front of the tibia is an important consideration in patients who have suffered repeated ACL graft failures, and it may be performed together with or before a revision ACL reconstruction.

Double-Level Osteotomy

When the deformity arises from both the femur and the tibia or the required correction is larger in magnitude, a double-level osteotomy corrects both bones to restore alignment while keeping the joint line level.

Because alignment affects every structure in the knee, osteotomy is often part of a broader joint preservation plan:

• Cartilage restoration: Procedures that repair or replace damaged cartilage are protected by unloading the compartment in which the new cartilage must heal.
• Meniscal transplantation: A new meniscus placed in an overloaded compartment is at high risk of failure, so correcting alignment is a key part of the operation when malalignment is present.
• Ligament reconstruction: A bowlegged knee places added stress on reconstructions of the posterolateral corner and ACL, and excessive tibial slope stresses ACL grafts. Correcting alignment or slope protects these reconstructions.

Osteotomy is typically performed with a short hospital stay or on an outpatient basis. Recovery is driven by bone healing. Patients typically use crutches with protected weight-bearing for several weeks while the osteotomy consolidates, with motion and quadriceps activation beginning early to prevent stiffness. The specifics of the weight-bearing protocol will depend on which type of osteotomy was performed and whether additional procedures were done at the same time.

Strengthening advances as healing is confirmed on x-ray, with return to most activities around four to six months and full recovery generally within a year. Every patient receives a written protocol specific to the procedure performed.