u/greatindianortho

One of the most important lessons in knee surgery: if the alignment is wrong, your ACL graft will fail.

She came to us with a painful, unstable left knee.
The diagnosis? A combination that’s more common than people realize — genu valgum (knock knee deformity) with a ACL tear.

This put me into a dilemma of what should I do the deformity or the ligament because both are related to each other

The problem with just doing ACL reconstruction In a knock knee, the mechanical axis passes lateral to the knee centre. This means every time the patient walks, runs, or lands from a jump, the forces on that ACL graft are skewed. Studies consistently show that uncorrected valgus malalignment dramatically increases graft failure rates. You’re essentially rebuilding a rope and then hanging it at the wrong angle.

The plan: staged correction
We performed a Distal Femoral Osteotomy (DFO) — a lateral closing wedge — to correct the valgus deformity, fixed with a distal femoral locking plate. Simultaneously, ACL reconstruction was completed. The alignment is now corrected. The graft has a fighting chance.
Key takeaways for anyone reading this:

Alignment always trumps ligament reconstruction. Fix the bone first, or alongside.
Young active patients with valgus + ACL tears are not straightforward ACL cases.
Skipping the osteotomy is a shortcut to revision surgery.

She is now 7 weeks post-op, full weight bearing, and starting rehab. 💪

happy to discuss DFO indications, the combined vs staged approach debate, and rehab timelines.​​​​​​​​​​​​​​​​

Uploading a short intraoperative clip from today’s ACL reconstruction.
What you’re seeing is a bioabsorbable interference screw being driven in to secure the graft inside the tibial tunnel. This is one of those moments that patients never get to see, and have I decided to share so that it fulfil is your thirst of knowledge.
A few things to note.
A] The screw is bioabsorbable, meaning it gradually dissolves and is replaced by bone over 12–18 months

B] Proper screw placement is critical , too proud or too deep and you risk graft impingement or poor fixation strength

C] The tactile feedback as it seats flush is something you learn to trust over hundreds of cases

For those post-op and curious: This tiny screw is doing a lot of the heavy lifting in your early rehab weeks while the graft is still integrating.

Respect the timeline we as surgeons give u ..
Happy to answer questions .

Sever varus deformity,the classic bow-legged collapse that happens when the medial compartment gives up over years of untreated osteoarthritis.

Joint space nearly gone.Every single step she took, bone was meeting bone with nothing meaningful in between.
The mechanical axis was so far off that her gait had reorganised itself entirely around the pain — which is exactly why she limped, and exactly why she thought the limp was just her now.

We talked through the options . At this stage, there were no half-measures left. Injections would have been a temporary kindness at best. The only real answer was bilateral total knee replacement, and we went ahead.

N three months later.
She walked into my OPD for her follow-up. And I watched her come through the door ,and she wasn’t limping. She just walked in. Normally.
Like it was nothing. She sat down, told me her pain was gone,

She didn’t make a big deal of it.