Faculty Bibliography

PURPOSE/OBJECTIVE:To systematically review existing literature to define the rate and types of complications of anterior closing wedge osteotomy (ACWO) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR). METHODS:A systematic query of PubMed, Embase and Scopus databases was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2025. Studies were included if they reported complications in patients undergoing ACWO with concurrent ACLR. Data on demographics, surgical technique, fixation method, graft type, posterior tibial slope (PTS) correction and complications were extracted. Data were described narratively and presented as frequencies with ranges in order to avoid potential bias and misleading conclusions from pooling heterogeneous data. RESULTS:Twelve retrospective case series comprising 505 patients undergoing combined ACLR with ACWO were included. The overall complication rate was 9.7% (range: 0%-82.8%). The most common complication was symptomatic hardware (6.1%), accounting for nearly half of all reported complications. The overall rate of postoperative ACL graft rupture was 1.7%. Other reported complications included arthrofibrosis (0.4%), infection (0.2%) and malunion (0.2%). No reported cases of nonunion, hinge fracture, neurovascular injury or loss of sagittal plane correction were reported. CONCLUSION/CONCLUSIONS:ACWO performed during ACLR demonstrates a clinically relevant complication rate, with hardware-related symptoms constituting the most frequent adverse event. Severe complications were rare. ACWO may reduce but does not eliminate the risk of ACL graft failure in patients with elevated PTS and appears to be a safe and effective option when PTS correction is indicated. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND/UNASSIGNED:The patient-specific instrumentation (PSI) used during corrective high tibial osteotomies and distal femoral osteotomies is based on 3-dimensional computed tomography (3D CT). Plain radiographs are typically used preoperatively to determine the need for an osteotomy; however, it is unclear how well measurements on plain radiographs correlate with 3D CT. PURPOSE/HYPOTHESIS/UNASSIGNED:The purpose of this study was to evaluate the correlation between coronal and sagittal alignment measurements on plain radiographs and 3D CT. It was hypothesized that there would be high agreement in the measurement of the mechanical medial tibial width ratio (mMTWr) and the medial posterior tibial slope (PTS) between both modalities. STUDY DESIGN/UNASSIGNED:Cohort study (diagnosis); Level of evidence, 3. METHODS/UNASSIGNED:Patients who underwent hip-to-ankle CT as part of the preoperative workup before a corrective osteotomy from October 2020 to November 2023 were reviewed. Coronal (mMTWr) and sagittal alignment (medial PTS) were evaluated preoperatively by 2 raters on standing whole-leg radiographs and a lateral radiograph of the knee, respectively, and by semi-automated PSI software on 3D CT. Intraclass correlation coefficients (ICC) were calculated to assess interrater reliability for each measurement and to evaluate agreement between raters and the PSI software. RESULTS/UNASSIGNED:Complete data sets were obtained for 91 cases. The ICC between raters for preoperative mMTWR was 0.99. The ICC between the raters' measurements and the PSI software measurements of mMTWr was 0.99. The ICC between raters for preoperative PTS was 0.82. The ICC between the raters' measurements and the PSI software's PTS measurements was 0.63. CONCLUSION/UNASSIGNED:This study found that coronal measurements performed on whole-leg radiographs and 3D CT were highly correlated, with near-perfect agreement, and that medial PTS measurements showed moderate agreement between modalities. These data suggest that measurements on plain radiographs are reproducible and accurate for evaluating coronal alignment and PTS preoperatively. Surgeons can confidently use plain radiographs to assess whether or not a patient is a candidate for a knee osteotomy.

BACKGROUND:The indications for temporizing knee-spanning external fixation (KSEF) in the setting of knee dislocation (KD) are poorly defined, leading to significant uncertainty and inconsistency in clinical practice. This study aimed to analyze and describe the documented indications for temporizing KSEF in a series of patients with KDs. METHODS:A retrospective, multi-center review was conducted at two level I trauma centers from January 2001 to May 2024, identifying patients with documented KD treated with KSEF. Data were extracted from operative records, imaging, and clinical notes, and reviewed for demographics, injury characteristics, and documented indications for KSEF. A set of KSEF indications derived from the literature was developed a priori to individually assess the appropriateness of each KSEF application. Knees were classified as 'did not meet criteria' for KSEF only when both of the following conditions were true: (1) no predefined indication was met; and (2) there was no radiographic, clinical, or documented evidence of persistent post-reduction instability. RESULTS:A total of 33 patients with 36 documented KDs treated with KSEF were identified from a cohort of 289 multiple ligament injured knees (12.5 %). Of the 36 KDs, 28 (77.8 %) met the selected criteria for KSEF. The most common primary indications for KSEF were vascular injury, tibial plateau fracture-dislocation, inability to maintain tibiofemoral reduction via non-invasive means, and morbid obesity. The remaining eight KDs (22.2 %) did not meet criteria for KSEF either as isolated injuries or in the setting of "polytrauma." The rationale for KSEF application was cited as "polytrauma" in 6/8 (75.0 %) of these cases. CONCLUSION/CONCLUSIONS:Eight of the 36 (22.2 %) KSEF applications did not meet the predefined criteria for KSEF in the setting of KD, nor showed evidence of an inability to maintain tibiofemoral reduction via non-invasive means. Polytrauma is frequently cited in the literature as a primary indication for temporizing KSEF in the setting of KD without a clear definition. Further investigation into the role of temporizing KSEF is needed, particularly in the polytraumatized patient, to determine its specific role in the management of KDs.

BACKGROUND:Genu valgum is a known risk factor for recurrent patellar instability, and surgical correction of deformity can be utilized as part of the management strategy to improve tracking and optimize outcomes. Tibial tuberosity-trochlear groove (TT-TG) distance is a widely used objective measurement of the lateral quadriceps force vector in patients with patellar instability. The evidence documenting the effect of lateral opening wedge distal femoral osteotomy (LOWDFO) and medial closing wedge high tibial osteotomy (MCWHTO) on TT-TG is limited, with minimal data directly comparing the biomechanical implications of one versus the other. PURPOSE/HYPOTHESIS/OBJECTIVE:The purpose of this study was to directly compare LOWDFO and MCWHTO using a computer model to determine the effect of each osteotomy on TT-TG distance. It was hypothesized that LOWDFO would have a greater effect on TT-TG distance, given the position farther away from the tibial tubercle. STUDY DESIGN/METHODS:Descriptive laboratory study. METHODS:A total of 22 knees from 21 patients with patellar instability and valgus malalignment were processed using 3D Slicer (Version 5.4.0) to convert their respective DICOM images into .stl mesh files to be used with Fusion (Autodesk; Version 2601.1.37) computer-aided design software. LOWDFOs and MCWHTOs were then simulated from 0° to 12° in 2° increments. TT-TG distance was then measured after each osteotomy. RESULTS:< .001). CONCLUSION/CONCLUSIONS:LOWDFO results in a significantly larger magnitude of change in the TT-TG compared with MCWHTO, with distal femoral osteotomy at almost a 1:1 change with TT-TG compared with the correction angle, and high tibial osteotomy about 1:4. CLINICAL RELEVANCE/CONCLUSIONS:The LOWDFO may be a more effective procedure in reducing the TT-TG distance, which is important when addressing patellar instability in patients with valgus malalignment.

Patient-specific instrumentation (PSI) may help improve outcomes following high tibial osteotomy (HTO). Three-dimensional preoperative planning allows for multiplanar osteotomy templating that can precisely restore the mechanical axis while limiting unintended sagittal plane abnormalities, facilitating execution of complex biplanar corrections. Patient-specific cutting guides and anatomically contoured implants reduce risk for intraoperative complications and streamlines operative efficiency. Though lacking long-term data to establish clinical superiority of PSI over traditional HTO techniques, early reports demonstrate PSI is highly accurate, safe, and effective. Understanding the advantages and limitations of PSI is crucial in making informed decisions when implementing this new technology in osteotomy surgery.

BACKGROUND AND OBJECTIVE/UNASSIGNED:High tibial osteotomy (HTO), particularly through a medial opening-wedge technique [medial opening-wedge high tibial osteotomy (MOWHTO)], is a well-established surgical intervention for correcting varus malalignment and unloading the medial compartment in younger patients with early osteoarthritis or secondary ligamentous or chondral deficiency. However, conventional methods pose high technical demands for accurate alignment, often requiring repeat intraoperative fluoroscopy. Patient-specific instrumentation (PSI), developed through three-dimensional (3D) imaging and printing technologies, offers a promising solution by enabling precise preoperative planning and intraoperative execution via customized cutting guides. This narrative review aims to explore the inception and current data surrounding PSI in HTO, specifically in regards to radiation, cost effectiveness, hinge fractures, surgical accuracy, and multiplanar osteotomies. METHODS/UNASSIGNED:A comprehensive literature review was conducted using PubMed, incorporating studies related to "high tibial osteotomy", "virtual planning", "patient-specific instrumentation", and "3D planning" published up to March 1st, 2025. Relevant English-language studies were included to summarize the use and outcomes associated with PSI in HTO. KEY CONTENT AND FINDINGS/UNASSIGNED:traditional osteotomy are nearly identical, with potential for even further monetary savings in revision rates, survivorship, and downstream healthcare utilization. Current evidence on hinge fracture prevention remains inconclusive, but PSI offers theoretical benefits through controlled cutting depths, hinge-pin technology, and anatomically tailored guides. Studies report alignment deviations typically within 2° of the preoperative plan in both coronal and sagittal planes, surpassing traditional and navigation-assisted techniques. CONCLUSIONS/UNASSIGNED:PSI represents a significant advancement in the execution of high tibial osteotomies, offering increased surgical accuracy, reduced radiation exposure, and enhanced procedural efficiency. It holds particular value in complex or multiplanar deformities where traditional techniques are limited. Although cost and hinge fracture data remain areas for further investigation, the growing body of evidence supports PSI's clinical utility and reproducibility. As 3D planning technologies and guided manufacturing become more accessible, PSI is well-positioned to become a standard adjunct in knee realignment procedures.

The knee is a complex joint composed of a combination of osseous, musculotendinous, ligamentous, neurovascular, and intra-articular structures, which must be taken into consideration when performing surgical approaches, whether it be for trauma, replacement, or joint preservation surgery. A wide variety of surgical approaches exist for exposure of the lateral side of the knee, including approaches to the distal femur, knee joint, and proximal tibia. Care must be taken to choose the appropriate approach depending on the procedure being performed to best preserve and protect important neurovascular structures. This review thoroughly describes the most frequently used surgical approaches to the lateral knee. The common themes and anatomical considerations presented in this review, in combination with continued experience, can provide surgeons with familiarity with various ways of accessing the knee joint.

The need to perform revision anterior cruciate ligament reconstruction (ACLR) has several etiologies such as infection, arthrofibrosis, cyclops lesions, and graft failure, which should be distinguished before revision ACLR. Even the definition of graft failure varies within the literature. ACLR graft failure falls into modifiable, surgeon-controlled factors, such as tunnel position, graft choice, and alignment, and nonmodifiable factors, such as patient age, tissue quality, or secondary traumatic reruptures. In this review, we describe a facile framework for the workup of modifiable ACLR graft failure.