The role of proximal tibial osteotomy in joint preservation

Introduction: Tibial osteotomy has a role in various aspects of joint preservation. Proper diagnosis and addressing all aspects of alignment both for focal cartilage lesions to support restorative repair procedures as well as in treatment of earlier phases of knee osteoarthritis in well selected patients. Malalignment of the leg axis is known to result in chronic overloading and thus contributing to the development of focal lesions as well as osteoarthritis. Objectives: To provide a comprehensive summary of the current state of utilization of tibial osteotomies in conjunction with other joint preserving procedures and to synthesize the current scientific evidence for the use of osteotomies in the setting of cartilage injuries. Methods: PubMed, Medline, Cochrane Systematic Reviews, and Clinical Keys were searched by the first author (M.H.) to validate that all papers of relevance to the area studied were included. Databases were searched comprehensively, and original research, systematic reviews, and meta-analysis were included at the authors’ discretion. References of selected articles were analyzed manually. Data from selected publications focused on tibial osteotomy were summarized. Results: Leg axis and patellofemoral alignment must be considered as important risk factors for failure of restorative cartilage procedures in the knee joint. Alignment-correcting osteotomies play a crucial role in enhancing clinical results of cartilage repair surgeries especially in the long-term. Through the redistribution of load, the biomechanical environment of the joint is optimized, and the induced or transplanted repair tissue is protected against overloading, facilitating enhanced tissue maturation. Recent evidence suggests that even small deviations from a neutral axis (<5°) should be corrected by osteotomy. Preoperative investigation of potential malalignment would therefore be beneficial in every patient who is considered for cartilage repair and joint preservation. Conclusion: Joint preservation procedures profit from addressing alignment by proximal tibial osteotomy. Unloading osteotomies are of utmost importance to facilitate a joint environment in which these procedures can be carried out successfully, reliably contributing to the long-term durability of cartilage restoration.