Are cartilage repair and restoration procedures in the knee without respecting alignment fruitless? A comprehensive review

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.

Keywords

• Cartilage restoration procedures
• Knee
• Realignment osteotomy