Fig 1

Fig. 1

Push towards borderline indication osteotomy. Large and/or uncontained defects. A-C, osteochondritis dissecans of the medial femoral condyle in the left knee of a 35 years old male: large (6 cm2) uncontained defect (white arrows). Left lower limb offers a hip-knee-ankle (HKA) angle of 1.5º in varus. D, E, and F, patient received high tibial osteotomy and the “sandwich” technique with autologous bone grafting and autologous chondrocyte implantation (ACI). Good clinical and imagery outcome at 2 years. MRIs in T2 fat sat weighted images.

Fig 2

Fig. 2

Push towards borderline indication osteotomy. Revision surgery case. Osteochondritis dissecans (OCD) of the medial femoral condyle with varus malalignment in the right knee of a 46 years old mountain farmer. He was referred for remaining pain after primary surgical treatment by arthroscopic fragments removal plus a closing wedge type corrective high tibial osteotomy (HTO). A-D, Failure of primary surgery. A, Computed Tomography with 3D reconstructions. Posterior view showing persistence of a defect involving 50% of the carrying surface of the medial condyle. B, Tunnel view at 45° depicting the limited remaining medial condyle in flexion. C, Standing hip to ankle radiograph showing that osteotomy was probably insufficient as it corrected the alignment to neutral only. D-I, Revision surgery. D, Further open wedge HTO correction of 4° to place the mechanical axis on 35% lateral (Fujisawa Point) fixed by medially place Tomofix plate. E and F, Debridement of OCD ground by removal of the sclerosis and deep cancellous bone drilling. G, preparation and suturing of a type I/III resorbable collagen membrane (Chondro-Gide, Geistlich Pharma AG) on the uncontained defect. H, complete filling of defect with 1:1 mixture of granules of hydroxyapatite granules (Orthoss, Geistlich Pharma AG) and cancellous bone retrieved from the supracondylar area. Finalizing the suturing of the Matrix allowing reshaping condylar convexity. I, Postoperative standing AP radiograph at 6 years showing the filled up area of the medial condyle and the maintained joint line. Patient still working as mountain farmer. J-M, At 13 months: removal of osteotomy plate and control arthroscopy plus biopsy. J and K: Arthroscopy confirming the restored medial condyle and the substantial thickness of the cartilage regenerate. Biopsy performed in the original defect. L and M, Histology with hematoxylin and eosin (HE) and Masson's trichrome staining shows newly formed bone and fibrocartilage coverage with hyaline like areas.

Fig 3

Fig. 3

Push towards borderline indication osteotomy. Asymmetry. A-C, Full-thickness articular cartilage defect (2 cm2) of the lateral femoral condyle in the left knee of a 21 years old male. Left lower limb is well aligned, whereas the right lower limb offers a hip-knee-ankle (HKA) angle of 2.5º in varus. D and E, patient received lateral open wedge distal femoral osteotomy for symmetrizing HKA angle, combined with arthroscopic microfractures of the defect.

Fig 4

Fig. 4

Unloading the patellofemoral compartment. A and B, Full-thickness articular cartilage defect (white arrows) on the most proximal and lateral part of the trochlea in a 39 years old female (2.2 cm2). History of patellar dislocation. Bilateral involvement. Complete illustration in this figure for the left knee only. C-E, Full radiologic malalignment screening: increased femoral anteversion (47⁰) and TT-TG distance (25 mm) on CT, patella alta (Caton-Dechamps index: 1.25) on knee x-rays and well aligned lower limbs on the standing hip to ankle radiograph. F-H, Patient received derotational femoral osteotomy, tibial tuberosity osteotomy with concomitant distalization and medialization, medial patella femoral ligament reconstruction and an AMIC procedure on the defect. Postoperative radiologic work-up: normal range femoral anteversion (17⁰) and TT-TG (15 mm), corrected patellar height (Caton-Dechamps index: 1), and slight varus deviation on the standing hip to ankle radiograph. I and J, CT arthrogram of the knee shows healing of the defect with adequate sagittal patella engagement index at 0.3.

Fig 5

Fig. 5

Unloading the patellofemoral compartment. A-D, Lateral distal patellar full-thickness articular cartilage defect in a 35 years old female (3.5 cm2). Biomechanical environment: tibial-tuberosity to trochlear groove distance (TT-TG) of 24 mm combined with patella alta (Caton-Deschamps index at 1.3). E-G, patient received tibial tuberosity osteotomy for anteromedialization and distalization, combined with autologous matrix-induced chondrogenesis (AMIC). H-K, Postoperative outcome at 2 years. MRIs in T2 fat sat weighted images.

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Abstract

Introduction

Both in the tibio-femoral and the patello-femoral (PF) joint, malalignment results in chronic overloading and plays a central role in the initiation, location and progression of cartilage defects. A vicious cycle is present, where erosion and secondary ligament attenuation promote further overload with progressive transition to osteoarthritis.

Objectives

To synthetize what is currently known about the importance of realignment osteotomies (OT) for cartilage repair in the knee.

Methods

We conducted a comprehensive literature search in PubMed and Medline databases. Original articles, systematic reviews, and meta-analysis were considered. References of selected articles were also analyzed manually. Data from selected publications were summarized in a narrative review.

Results

Despite the proven benefits of OT of redistributing mechanical load and establishing a favorable biomechanical environment, staged or concomitant OT is not standardized in cartilage repair today. Many cartilage surgeries could be improved if they allowed axial realignment in the preliminary necessity of patient care. Therefore, every patient designated for cartilage repair should have preoperative diagnostic investigations for malalignment. For lesions affecting the tibio-femoral joint, the break point for OT was lowered in the last decade from 5° to 3° of mechanical axis malalignment. In the PF joint, contact pressure is higher, with malalignment often related to several biomechanical factors. With current failure rates of cartilage repair being more prevalent in the PF joint, an approach where all contributing factors are addressed should be implemented.

Conclusion

Osteotomy remains the cornerstone improving the long-term durability of cartilage restoration in overloaded compartments.

Introduction

The first surgical osteotomy of the knee was performed in 1826 by John Rhea Barton for an ankylosed knee and the first book devoted to osteotomy was already published by Macewen in 1880.1x1Smith, JO, Wilson, AJ, and Thomas, NP. Osteotomy around the knee: evolution, principles and results. Knee Surg Sports Traumatol Arthrosc. 2013; 21: 3–22https://doi.org/10.1007/s00167-012-2206-0

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,2x2Macewen, W. Osteotomy With an Inquiry Into the Aetiology and Pathology of knock-knee, bow-leg, and Other Osseous Deformities of the Lower Limbs. Churchill, ; 1880

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Osteotomies gained progressive acceptance throughout Europe but were utilized mostly for corrections of deformities. Until the mid-twentieth century, surgical approaches for the treatment of osteoarthritis of the knee were limited, with arthrodesis as the main option for the most severe cases. Application of osteotomy for the treatment of unicompartmental osteoarthritis was first reported in Europe by Brittain in 1948 and then by Jackson in 1958. However, it became more prevalent in the 1960’s in Canada by Gariépy in Montreal (1964) and in the US by Coventry (1965) through his work at the Mayo Clinic.1x1Smith, JO, Wilson, AJ, and Thomas, NP. Osteotomy around the knee: evolution, principles and results. Knee Surg Sports Traumatol Arthrosc. 2013; 21: 3–22https://doi.org/10.1007/s00167-012-2206-0

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Around this period, there were early indications by surgeons that osteotomies would have a positive impact on cartilage repair. In 1959, Pridie presented a newly developed method for the treatment of osteoarthritic joint surfaces of the knee that he named subchondral drilling during the Congress of the British Orthopaedic Association. It was reported as a concise 11 lines publication in the Proceedings of the meeting, where Pridie mentioned that osteotomy to correct malalignment could be of additional benefit.3x3Pridie, KH. A method of resurfacing osteoarthritic knee joints. Proceedings of the British Orthopaedic Association. J Bone Joint Surg (Br). 1959; 41: 618–619

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In the same manner, Steadman was later able to confirm the important role of osteotomy in his approach of bone marrow stimulation by microfracture.4x4Sterett, WI and Steadman, JR. Chondral resurfacing and high tibial osteotomy in the varus knee. Am J Sports Med. 2004; 32: 1243–1249https://doi.org/10.1177/0363546503259301

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He was able to show, with combined medial opening wedge high tibial osteotomy and microfracture, a 91% survivorship at 7 years in a large case series of 106 active patients with varus gonarthrosis.

Realignment osteotomy became a well-established treatment for unicompartmental knee osteoarthritis. In this indication, it proved long-term efficiency with survival rates of 91% at 5 to 8 years, 84% at 9 to 12 years and 70% at 12 years.6x6Amendola, A and Bonasia, DE. Results of high tibial osteotomy: review of the literature. Int Orthop. 2010; 34: 155–160https://doi.org/10.1007/s00264-009-0889-8

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It was also shown to promote healing of the damaged articular cartilage on secondary arthoscopies.9x9Jung, WH, Takeuchi, R, Chun, CW et al. Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy. Arthroscopy. 2014; 30: 72–79https://doi.org/10.1016/j.arthro.2013.10.008

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Despite evidence of efficient operative care, the procedure was initially not highly implemented in practice,12x12W-Dahl, A, Robertsson, O, and Lohmander, LS. High tibial osteotomy in Sweden, 1998-2007: a population-based study of the use and rate of revision to knee arthroplasty. Acta Orthop. 2012; 83: 244–248https://doi.org/10.3109/17453674.2012.688725

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which may have been due to reports of high incidences of complications associated with the procedure, including peroneal nerve palsy, hinge fracture, delayed union, nonunion, hardware failure and loss of correction.14x14Miller, BS, Downie, B, McDonough, EB, and Wojtys, EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009; 25: 639–646https://doi.org/10.1016/j.arthro.2008.12.020

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Towards the end of the 20th century, surgeons adopted joint arthroplasty solutions for osteoarthritis (OA), and implemented isolated repair for the treatment of focal cartilage defects. However, over the last 15 years, literature reported lower risk of complications with osteotomies (7%), largely due to improvements in techniques, implants and control of potential risk factors.17x17Martin, R, Birmingham, TB, Willits, K, Litchfield, R, Lebel, ME, and Giffin, JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014; 42: 1118–1126https://doi.org/10.1177/0363546514525929

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This resulted in a renaissance of the procedure for unicompartmental OA of the knee.18x18Tschopp, B, Ngo, THN, and Martin, R. [Knee osteotomies : a renaissance ?]. Article in French. Rev Med Suisse. 2018; 14: 2254–2258

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Parallel to this, cartilage restoration procedures have gained interest for the treatment of focal cartilage defects and among patients who desire an active lifestyle.19x19McCormick, F, Harris, JD, Abrams, GD et al. Trends in the surgical treatment of articular cartilage lesions in the United States: an analysis of a large private-payer database over a period of 8 years. Arthroscopy. 2014; 30: 222–226https://doi.org/10.1016/j.arthro.2013.11.001

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Besides the technique of bone marrow stimulation, different grafting procedures also became available but there is no consensus on a gold standard as each procedure may have limitations. Indeed, many studies have demonstrated short-term success rates of various cartilage repair procedures, but long-term durability remains a challenge. Mithoefer et al20x20Mithoefer, K, McAdams, T, Williams, RJ, Kreuz, PC, and Mandelbaum, BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009; 37: 2053–2063https://doi.org/10.1177/0363546508328414

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have shown in their systematic review that microfracturing is related to deterioration of functional outcome scores in 47% to 80% after 2 years. Osteochondral autograft transfer can lead to a 55% failure rate at 10 years.21x21Bentley, G, Biant, LC, Vijayan, S, Macmull, S, Skinner, JA, and Carrington, RW. Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. J Bone Joint Surg British. 2012; 94: 504–509https://doi.org/10.1302/0301-620x.94b4.27495

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Autologous chondrocyte transplantation (ACI), the current technically most sophisticated and costly cartilage restoration procedure, is known to be associated with 25% of unsatisfied patients at 12 years.22x22Minas, T, Von Keudell, A, Bryant, T, and Gomoll, AH. The John Insall Award: a minimum 10-year outcome study of autologous chondrocyte implantation. Clin Orthop Relat Res. 2014; 472: 41–51https://doi.org/10.1007/s11999-013-3146-9

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Therefore, there remains high potential of improvement, as most patients presenting with cartilage defects are quite young. Among other reasons, there may be a strong association with relatively few of these procedures being performed in conjunction with realignment osteotomy.24x24Westermann, RW. Editorial commentary: when performing cartilage restoration, please don't put down the osteotomy saw!. Arthroscopy. 2019; 35: 147–148https://doi.org/10.1016/j.arthro.2018.09.014

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Despite the proven benefits of osteotomies creating a favorable biomechanical environment, the procedure is not standardized in cartilage repair. The Patient Registry report of 2018 (n = 535)25x25Conley, C, McNicholas, M, and Biant, L. The ICRS patient registry report. in: The International Cartilage Regeneration & Joint Preservation Society Registry Steering Committee. ; 2018

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and 2020 (n = 1945)26x26Asplin, L, Conley, C, and McNicholas, M. The ICRS patient registry report. in: The International Cartilage Regeneration & Joint Preservation Society Registry Steering Committee. ; 2020

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of the International Cartilage Regeneration and Joint Preservation Society revealed concomitant osteotomy in all cartilage restorations procedures in only 1.5% and 1.7% of the cases, respectively. Importantly, differences for the implementation of osteotomy in patient care are observed worldwide. In 2019, an analysis of the German Cartilage Registry (n = 4986 patients) revealed combined osteotomy in 46% of cartilage repair procedure.27x27Faber, S, Zellner, J, Angele, P et al. Decision making for concomitant high tibial osteotomy (HTO) in cartilage repair patients based on a nationwide cohort study of 4968 patients. Arch Orthop Trauma Surg. 2020; 140: 1437–1444https://doi.org/10.1007/s00402-020-03476-6

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In 2014, Montgomery et al28x28Montgomery, SR, Foster, BD, Ngo, SS et al. Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2070–2075https://doi.org/10.1007/s00167-013-2614-9

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analyzed US billing codes from 2004 to 2009 for 38,203 cartilage repair and restoration procedures. They reported that osteotomy was performed in conjunction with ACI in 6.3%, associated with osteochondral allograft in 4.5% and less than 1% in conjunction with microfractures and mosaicplasty. On the other hand, Growd et al29x29Gowd, AK, Cvetanovich, GL, Liu, JN et al. Management of chondral lesions of the knee: analysis of trends and short-term complications using the National Surgical Quality Improvement Program Database. Arthroscopy. 2019; 35: 138–146https://doi.org/10.1016/j.arthro.2018.07.049

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analyzed trends for the management of chondral lesions in the knee in the US between 2010 and 2016 and observed a linear increase in osteochondral autograft transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation. Overall, cartilage restoration procedures increased by 206%.

Surgeons appear to be seeking more for cartilage restoration techniques (osteochondral transplantation, ACI) and seem to lack or ignore information to optimize the biomechanical environment.30x