The Role of Osteotomy in the Multiple-Ligament-Injured Knee

  • Hervé OuanezarEmail author
  • Sava Turcan
  • Anil S. Ranawat


Patients with instability after multiple-ligament-injured knee (MLIK) often present with many concomitant pathologies, including limb malalignment, meniscal incompetence and cartilage defects. Surgical treatment remains challenging; yet, interest has recently increased with numerous anatomic studies and technical notes published about ligament reconstructions, ligament augmentations, and ligament repairs in and around the knee. However, biological healing of soft tissues can be uncertain and inefficient to control forces and torques applied to the joint. In this context, axis impairment creating mechanical disorders need to be recognized, analyzed and corrected. Associated or not with soft tissue procedures, osteotomy is a surgical option that is a part of the knee surgeon’s modern armamentarium. This chapter highlights the role of osteotomy to restore stability and function in MLIK as a means of ensuring success in the long-term outcome.


Osteotomy Multiple-Ligament-injured knee Limb axis Slope ACL PCL HTO DFO 



Anterior Cruciate Ligament




Body Mass Index


Distal Femoral Varus Osteotomy




High Tibial Osteotomy


Lateral Collateral Ligament


Medial Collateral Ligament


Multiple-Ligament-Injured Knee


Magnetic Resonance Imaging


Posterior Cruciate Ligament


Posterolateral Corner


Posteromedial Corner


  1. 1.
    Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment for chronic posterolateral corner deficiency in the varus knee. Am J Sports Med. 2007;35:1844–50.CrossRefGoogle Scholar
  2. 2.
    Giffin JR, Vogrin TM, Zantop T, Woo SL-Y, Harner CD. Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med. 2004;32:376–82.CrossRefGoogle Scholar
  3. 3.
    Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL-Y, Harner CD. Importance of tibial slope for stability of the posterior cruciate ligament—deficient knee. Am J Sports Med. 2007;35:1443–9.CrossRefGoogle Scholar
  4. 4.
    Goradia VK, Van Allen J. Chronic lateral knee instability treated with a high tibial osteotomy. Arthrosc J Arthrosc Relat Surg. 2002;18:807–11.CrossRefGoogle Scholar
  5. 5.
    Ranawat AS, Nwachukwu BU, Pearle AD, Zuiderbaan HA, Weeks KD, Khamaisy S. Comparison of lateral closing-wedge versus medial opening-wedge high tibial osteotomy on knee joint alignment and kinematics in the ACL-deficient knee. Am J Sports Med. 2016;44:3103–10.CrossRefGoogle Scholar
  6. 6.
    Voleti PB, Wu IT, Degen RM, Tetreault DM, Krych AJ, Williams RJ. Successful return to sport following distal femoral varus osteotomy. Cartilage 2017:194760351774354.Google Scholar
  7. 7.
    Sonnery-Cottet B, Mogos S, Thaunat M, Archbold P, Fayard JM, Freychet B, et al. Proximal tibial anterior closing wedge osteotomy in repeat revision of anterior cruciate ligament reconstruction. Am J Sport Med. 2014;42:1873–80. (Epub 2014).CrossRefGoogle Scholar
  8. 8.
    Dejour D, Saffarini M, Demey G, Baverel L. Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sport Traumatol Arthrosc. 2015;23:2846–52.CrossRefGoogle Scholar
  9. 9.
    Yamaguchi KT, Cheung EC, Markolf KL, Boguszewski D V., Mathew J, Lama CJ, et al. Effects of anterior closing wedge tibial osteotomy on anterior cruciate ligament force and knee kinematics. Am J Sports Med. 2017:36354651773676.Google Scholar
  10. 10.
    Naudie DDR, Amendola A, Fowler PJ. Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med. 2004;32:60–70.CrossRefGoogle Scholar
  11. 11.
    Tischer T, Paul J, Pape D, Hirschmann MT, Imhoff AB, Hinterwimmer S, et al. The impact of osseous malalignment and realignment procedures in knee ligament surgery: a systematic review of the clinical evidence. Orthop J Sport Med. 2017;5:232596711769728.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Hervé Ouanezar
    • 1
    Email author
  • Sava Turcan
    • 1
  • Anil S. Ranawat
    • 1
  1. 1.Sports Medicine, Hospital for Special SurgeryNew YorkUSA

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