Eva Bax

The global burden of knee osteoarthritis (KOA) is increasing, particularly among younger and physically active individuals, highlighting the need for joint-preserving treatments. In this context, osteotomy has emerged as an important treatment option due to its ability to preserve the native joint and delay the need for knee arthroplasty.

This thesis aims to advance four interrelated domains of KOA research: imaging assessment, lower limb malalignment, optimization of osteotomy care, and the impact of prior osteotomy on subsequent total knee arthroplasty outcomes. Part I shows that radiographic joint space measurements are influenced by patient positioning and should be interpreted using both compartments rather than a single compartment. Part II demonstrates that lower limb malalignment, including both bony and intra-articular components, is associated with the development and progression of KOA and may originate during growth and physical activity. Part III focuses on improving osteotomy care through surgical planning, assessment of bone healing, biomaterials, and standardized outcome evaluation. Part IV shows that prior osteotomy does not negatively affect total knee arthroplasty outcomes, thereby supporting osteotomy as a durable joint-preserving strategy.

Overall, this thesis demonstrates that lower limb malalignment is a key factor in the onset and progression of KOA. It emphasizes the importance of accurate imaging, understanding of mechanical alignment, and refined surgical techniques for joint preservation, with the aim of maintaining function, mobility, and quality of life, particularly in younger, active patients. This thesis concludes with the overarching dream for future research: “Realigning the Future”, in which understanding the development of malalignment is considered essential for the shift from treatment toward true prevention.