Available online 18 February 2026, 151206

Author links open overlay panelMatthew Nasra 1 2, Abhinaba Chatterjee 1 2, Michael A. Zacchilli 1 2 3Show moreAbstract

The treatment of knee malalignment has entered a renaissance period. Recent refinement in our understanding of the disease process continues to support early intervention strategies and corrective surgeries. MRI imaging provides the potential for the early detection of chondral damage and may enhance our ability to accurately indicate patients when they become clinically available. Available advanced imaging modalities including weightbearing CT, EOS®, and hybrid three-dimensional modeling are in the early phases of clinical implementation but are already revolutionizing presurgical planning. A deeper understanding of soft tissue balance is helping surgeons systematically reduce outliers in surgical correction. Utilizing these resources, surgeons are increasingly capable of addressing deformity in multiple planes while accounting for concomitant procedures. Even in salvage situations, new surgical options such as the implantable shock absorber are diversifying surgical treatment options for malalignment patients. In summary, innovation is driving rapid growth in the treatment of knee malalignment which may herald a new era in osteotomy.

Introduction

Knee malalignment is a major contributor to disability in orthopedic populations. It predisposes to early stages of joint degeneration and chondromalacia and directly impacts the progression of osteoarthritis. It is also a major contributing factor to meniscal pathology, ligamentous injury, and patellar instability while simultaneously impacting the failure rate of surgeries designed to address these pathologies. The surgical correction of malalignment is therefore a logical target for surgeons to preserve healthy joints and treat diseased joints. In the late 19th century, the treatment of malalignment through corrective osteotomy was introduced as an innovative treatment strategy in the field. Nonetheless, challenges in accurately and safely correcting malalignment, coupled with the emergence of arthroplasty a century later, have stunted the utilization of alignment correction surgeries over the last four decades. However, recent innovations in our understanding of disease progression, evaluation of patients, and surgical planning and instrumentation may herald the reemergence of osteotomy as a core treatment option.

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Access through your organizationSection snippetsNatural History of Knee Malalignment

Knee osteoarthritis (OA) is one of the most prevalent chronic musculoskeletal disorders and a major contributor to global disability, affecting 22% of adults over the age of 40 and contributing to billions of dollars in healthcare expenditures annually. Among the numerous biomechanical and biological factors associated with knee OA, lower limb malalignment has emerged as an important determinant of disease initiation and progression.1,2

Research has confirmed that knee malalignment magnifies the

Classification

Several assessment tools have been developed to describe knee malalignment and provide a framework for understanding its biomechanical and clinical implications. Traditional evaluation relies on standard measurements of MPTA and LDFA (both anatomic and mechanical), the Hip–Knee–Ankle (HKA) angle, Mechanical Axis Deviation (MAD), and the Joint Line Convergence Angle (JLCA) to quantify the magnitude and location of coronal plane deformity. More comprehensive strategies, such as the system

Surgical Planning

Precise surgical planning is essential for achieving optimal results in knee malalignment surgery. Ideal postoperative limb alignment is strongly associated with improved clinical outcomes. Under-correction is linked to early failure, increased risk of revision osteotomies or arthroplasty, and inferior patient reported outcomes. Conversely, over-correction may result in poor cosmesis, lateral compartment degeneration, increased shear stress on cartilage, and persistent pain.

Deformity-based Planning

A fundamental

Rehab: Weightbearing

Postoperative rehabilitation after owHTO remains a topic of ongoing debate, particularly regarding the timing and extent of weight-bearing. One of the primary considerations is the need for bony union at the osteotomy site, which influences time to weightbearing. Despite the increasing frequency of OWHTO in clinical practice, there is currently no clear consensus among osteotomy surgeons for a postoperative protocol, and many surgeons continue to adopt a conservative approach to weightbearing.86

Conclusion

Malalignment is common in the general population and has clearly been implicated as a risk factor for joint degeneration. Our understanding of progressive natural history of malalignment is rapidly increasing, and our understanding of kinesiology and imaging characteristics has improved our ability to classify malalignment. Novel imaging techniques including MRI bone biomarkers and sub-segmented chondral T2 relaxation may allow for more accurate prediction of joint degeneration before chondral

Declaration of competing interest

"Dr. Zacchilli is a member of the AANA Emerging Leaders and Communications and Technology Committees and has received compensation as a paid consultant for Globus Medical. The remaining authors declare no competing interests."

Acknowledgments

None

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