Joint Preservation & Osteotomy

If you have been told you might need a knee replacement — but you are 45, or you ski, or you have another twenty active years you are not ready to give up — there is a question worth asking before you book the surgery. Is the cartilage in your knee actually worn out everywhere? Or is one compartment getting more stress than it was designed to handle, while the rest of the joint is still working? That distinction is the whole point of joint preservation. End-stage diffuse arthritis needs a new joint. Mechanical arthritis — where one part of the knee is being overloaded by alignment, kneecap position, ligament instability, or focal cartilage damage — often does not. Realigning the forces, repairing the cartilage, and reconstructing the failed ligament can keep the native joint working for another decade or more.

This page is the sub-specialty hub for joint preservation surgery. It pairs with the dedicated procedure pages for MACI cartilage repair and cartilage transplant (OATS & osteochondral allograft) — cartilage operations that are commonly combined with osteotomy — and with patellar instability and MPFL reconstruction for the patellar realignment side. Here we cover what joint preservation actually means and who it is for, why some patients are not joint replacement candidates, the five preservation procedures with sub-specialty depth on AMZ-TTO and revision TTO, the MISHA implantable shock absorber, when osteotomy is combined with cartilage or ligament work, prehabilitation, the surgical day, the long bone-healing recovery, the realistic risks, common patient concerns, insurance and cost, patient outcomes including Peyton's TTO and the lifeguard's dual-osteotomy story, when to seek a sub-specialty second opinion (especially for revision osteotomy), and access at HSS in New York and Stamford, CT.

What Joint Preservation Means and Who It Is For

Joint preservation is a philosophy as much as a procedure. The goal is to keep your native cartilage, ligaments, and bone working together for as long as possible — using realignment, soft-tissue reconstruction, and biological repair before considering joint replacement. For the right patient, that decision can mean a decade or more of additional active use of the knee they were born with. As Dr. Strickland describes the patients who come to her for joint preservation: many are young people with old knees — not really candidates for knee replacement yet, but with pain or instability significant enough that ignoring it is no longer an option. Joint preservation is the toolkit that fits in between “wait and watch” and “new joint.”

The toolkit includes:

• Realignment osteotomy — surgically resetting bone alignment to move load off damaged cartilage onto healthy cartilage. The four variants (AMZ-TTO, distalization TTO, HTO, DFO) each address a different alignment problem.
• Cartilage restoration — repairing focal cartilage defects with techniques like MACI (autologous cultured chondrocytes on a porcine collagen membrane), OATS or osteochondral allograft, and CartiHEAL. Often performed in the same operation as an osteotomy so the realignment protects the repair.
• Ligament reconstruction — restoring stability to a knee whose ligaments are no longer doing their job, including MPFL reconstruction for the kneecap and ACL reconstruction for the central pivot.
• The MISHA Knee System — an FDA-approved extra-articular implantable shock absorber that mechanically unloads the medial compartment without bone cuts, joint surface alteration, or commitment to a joint replacement. One of the few non-arthroplasty surgical options for early-to-moderate isolated medial compartment OA.
• Biologic and conservative adjuncts — gel injections, arthroscopic chondroplasty for small flap-type cartilage defects, PRP and other regenerative options, and structured rehab as either standalone treatment in earlier-stage disease or as adjuncts to surgery.

Why Some Patients Are Not Replacement Candidates

Knee replacement is the right answer for the right patient. It is the wrong answer for the wrong patient — and recommending a replacement to a patient who would do better with a preservation procedure commits them to a revision conversation in their lifetime that they did not need to have. The categories of patient where joint preservation deserves a serious look before arthroplasty:

• Too young for arthroplasty — partial or total knee replacement in a 30- or 40-year-old commits the patient to a revision in their lifetime. Modern implants do not last forever, and revision arthroplasty is more complex than primary. Preserving the native joint and addressing the focal mechanical problem first preserves the option to do a replacement later if needed.
• Single-compartment disease — if only the medial compartment is worn (with intact lateral compartment, ACL, and meniscus), the diagnosis is mechanical medial-compartment overload, not whole-joint arthritis. HTO, MISHA, or unicompartmental options become real, not just total replacement.
• Instability with cartilage damage — a patient with recurrent patellar dislocation and a focal trochlear or patellar chondral lesion is a candidate for combined MPFL reconstruction plus cartilage repair plus (when indicated) AMZ-TTO — not for early patellofemoral arthroplasty.
• Alignment issues that have never been corrected — significant varus or valgus deformity that has been silently overloading one compartment for years. The replacement is the symptom; the alignment is the cause. Correct the cause and the symptom often does not require an implant.
• Patellofemoral-only disease — isolated patellar or trochlear cartilage wear in a young, active patient is rarely a total knee replacement problem. Realignment, cartilage repair, or in some cases patellofemoral arthroplasty is the more anatomically appropriate operation. See Dr. Strickland's discussion of patellofemoral joint preservation versus patellofemoral arthroplasty.

The bone-on-bone, multi-compartment, end-stage arthritis patient is a replacement candidate. The young, active, single-compartment, focal-damage, malaligned, or instability-driven patient is a preservation candidate — and sorting one from the other is what sub-specialty joint preservation surgery is.

The Five Joint Preservation Procedures at a Glance

Five procedures, five different anatomic problems. Choosing the right one starts with imaging that characterizes the alignment, the location of cartilage wear, the patellar tracking, and the meniscus and ligament status — then matching the procedure to the problem.

Revision TTO is a sub-specialty offering layered on top of these five — correcting a prior failed or symptomatic tubercle osteotomy. Each of the five primary procedures is described below in clinical depth, in the order in which they are most commonly considered for new patients.

Anteromedialization TTO (AMZ-TTO / Fulkerson)

Anteromedialization tibial tubercle osteotomy — commonly called the AMZ-TTO or the Fulkerson osteotomy — repositions the bony attachment of the patellar tendon on the tibia anteriorly and medially. The combined movement does two things at once: it shifts the patella medially in the trochlear groove (correcting lateral patellar tracking), and it lifts the patella anteriorly off the trochlea (offloading worn cartilage on the lateral facet of the patella). For the right patient with patellar maltracking and patellofemoral cartilage wear, AMZ-TTO is the most common patellar realignment osteotomy.

The biomechanical basis — Dr. Strickland's cadaveric model

In a controlled cadaveric study, Dr. Strickland and colleagues quantified patellar contact mechanics after TTO in the setting of patellofemoral dysplasia — the anatomic background that drives recurrent patellar instability and patellofemoral cartilage damage. The hypothesis: a simulated anteromedialization (AMZ) TTO would improve patellofemoral contact mechanics compared with a pure medialization TTO. The biomechanical reason: medialization alone shifts the patella into the groove but does not change the contact pressure on a worn lateral facet; adding an anterior lift redistributes the contact away from the damaged cartilage onto a less-loaded surface. The published study — Anteromedialization Tibial Tubercle Osteotomy Improves Patellar Contact Forces: A Cadaveric Model of Patellofemoral Dysplasia — provides the biomechanical support for choosing AMZ over pure medialization in patients with patellofemoral cartilage wear.

How AMZ-TTO is performed

Through an anterior incision over the tibial tubercle, an oblique osteotomy is made through the tubercle. The angle of the osteotomy cut determines the ratio of anteriorization to medialization — a steeper cut produces more anteriorization, a flatter cut more medialization. The amount of correction is calibrated to the patient's preoperative TT-TG distance (tibial tubercle to trochlear groove, measured on CT or MRI), the patellar cartilage status, and the patellar height. The repositioned tubercle is fixed with two cortical screws. The screws are typically left in place but can be removed later for hardware-related symptoms. AMZ-TTO is frequently combined with MPFL reconstruction when the patient also has patellar instability, with MPFL reconstruction plus TTO being one of the most common combined patellar stabilization operations, and with cartilage repair on the patella when patellofemoral cartilage wear is present.

Who is an AMZ-TTO candidate?

The classic candidate has patellar maltracking driven by underlying bony anatomy — an elevated TT-TG distance, lateral patellar tracking on imaging, and either cartilage wear on the lateral facet of the patella or recurrent patellar instability. Standing alignment films, MRI, and CT-based or MRI-based TT-TG measurement determine whether bony realignment is a meaningful contributor. The MPFL reconstruction page covers the soft-tissue side of patellar stabilization; the patellar instability and patellar pain pages cover the broader differential.

Distalization TTO for Patella Alta

A distalization TTO addresses patella alta — a kneecap that sits too high in the trochlear groove. By moving the bony attachment of the patellar tendon distally on the tibia, the patella is brought down to a normal height where it engages the trochlea earlier in flexion. Patella alta is a recognized risk factor for both patellar instability and patellofemoral cartilage damage, and distalization is the realignment that addresses the underlying anatomic cause. Patellar height is measured radiographically using the Caton-Deschamps index; values above the upper limit of normal define patella alta.

Distalization is often combined with anteromedialization in the same operation — an anteromedialization-distalization TTO — when the patient has both lateral tracking and patella alta. Combined with MPFL reconstruction, the operation addresses both bony and soft-tissue contributors to recurrent patellar instability. One of the technical considerations specific to distalization: bringing the patella too low (iatrogenic patella baja) is a known complication, and pre-operative planning of the exact distalization distance is part of why this operation belongs in a sub-specialty patellofemoral practice.

High Tibial Osteotomy (HTO)

HTO is the realignment osteotomy for the most common adult-active-patient problem in joint preservation: medial compartment arthritis with bow-legged (varus) alignment. The mechanical axis of the leg — the line from the hip to the ankle — passes through or medial to the center of the knee in varus alignment, concentrating weight-bearing forces on the inside compartment. Over time, that compartment wears out faster than the outside.

How HTO works

The osteotomy is made at the proximal tibia, just below the joint line. Two techniques exist:

• Medial opening wedge HTO (most common today) — the bone is cut from the medial side, opened like a book to a calculated angle, and a wedge of bone graft or synthetic substitute is placed in the gap. A locking plate fixes the correction. The mechanical axis ends up shifted laterally onto the healthier lateral compartment.
• Lateral closing wedge HTO — the bone is cut from the lateral side and a wedge is removed, then the cut is closed and fixed. Achieves the same alignment correction but historically associated with proximal tibiofibular joint issues and a slightly different leg-length effect.

Who is an HTO candidate?

The classic HTO candidate is an active patient under 60 with isolated medial compartment cartilage wear, varus alignment, and intact ligaments and meniscus. Patients commonly present with inside-of-the-knee pain that worsens with running, hiking, or downhill activities. Standing long-leg alignment films confirm the mechanical axis. MRI confirms the cartilage status — HTO works for medial-only damage; if the lateral compartment is also worn, the procedure does not help. For the right patient, HTO can delay knee replacement by a decade or more while preserving the native joint and full athletic function. It is a particularly appealing option for active patients in their 40s and 50s who want to keep skiing, running, or playing tennis.

Distal Femoral Osteotomy (DFO)

DFO is the femoral-side equivalent of HTO, used for lateral compartment arthritis with knock-kneed (valgus) alignment. The osteotomy is made on the femur just above the knee — typically as a lateral opening wedge or medial closing wedge — to shift the mechanical axis off the worn outside compartment onto the healthier inside compartment, fixed with a locking plate. The principle is identical to HTO: correct the mechanical reason the cartilage is wearing, give the healthy compartment the load, and the native joint can continue to function for years longer than it would after surgery to resurface the joint.

DFO is less common than HTO because lateral compartment arthritis with valgus alignment is itself less common. It belongs in the same conversation as HTO for patients with the appropriate alignment and cartilage pattern, and is similarly often combined with cartilage repair on the lateral femoral condyle in the same operation.

Revision TTO — Sub-Specialty Referral

A prior tibial tubercle osteotomy can fail or remain symptomatic for several reasons: malposition (the tubercle was moved too much, too little, or in the wrong direction for the underlying anatomy), nonunion (the bone did not heal at the osteotomy site), iatrogenic patella baja (the patella was brought too low and now impinges in flexion), persistent patellar maltracking despite the prior procedure, or symptomatic hardware. Revision osteotomy is technically more complex than primary because of prior hardware, scar tissue, altered anatomy, and the need to plan a corrected geometry that accounts for what the prior surgery did and did not accomplish.

Dr. Strickland's published work on revision TTO includes a case report on combined arthroscopy and revision tibial tubercle osteotomy in a 16-year-old female lacrosse player — a representative case of a young athlete needing both intra-articular debridement and a corrected tubercle position to return to sport — and an HSS Grand Rounds presentation, Grand Rounds from HSS: Revision TTO Returns Young Athlete to Sports, framing the surgical decision-making for revision TTO at one of the highest-volume orthopedic teaching hospitals in the country. For patients who have had a prior TTO that was either inadequate or has become symptomatic, revision is one of the situations where a sub-specialty referral materially changes the operative plan rather than just confirming what an outside surgeon proposed.

MISHA Implantable Shock Absorber

The MISHA Knee System — made by Moximed — is an FDA-approved extra-articular implantable shock absorber for medial compartment knee osteoarthritis. As Dr. Strickland frames it in her commentary on the device: when she sees an active patient with knee arthritis who has started to limit their activity, she runs through a long list of options ranging from exercise modifications and physical therapy to injections to a knee replacement. A common follow-up question is what is currently in development — what new surgery will be available if the patient can wait. Until MISHA, the answer was largely nothing in development that could meaningfully delay or substitute for arthroplasty in early-to-moderate medial compartment OA. MISHA is the answer that has changed.

How MISHA works — an extra-articular approach

Unlike osteotomy or arthroplasty, MISHA does not cut bone or alter the joint surfaces. The device is implanted on the medial side of the knee, outside the joint capsule, where it absorbs and redistributes load that would otherwise be applied to the worn medial compartment cartilage. The implant decreases the stress from activity — and therefore the pain due to medial compartment arthritis — without committing the patient to a joint replacement and without the bone-healing recovery of an HTO. Because the device is extra-articular and removable, it preserves the option of any future surgical pathway, including HTO, unicompartmental replacement, or total replacement if needed years later.

Who is a MISHA candidate?

The MISHA candidate is, broadly, an active adult patient with symptomatic isolated medial compartment osteoarthritis who has failed conservative care, is not yet a candidate for — or wants to delay or avoid — arthroplasty, and either is not an ideal HTO candidate or wants the faster recovery of a non-osteotomy option. MISHA is designed for early-to-moderate medial compartment OA, not end-stage bone-on-bone disease that has progressed to multi-compartment involvement. Specific candidacy criteria are reviewed at consultation. Dr. Strickland's husband, Dr. Andreas Gomoll, also at HSS, participated in the FDA clinical trials that led to the device's approval, giving the HSS sports medicine group early and direct experience with the implant. For background, see MISHA Knee System treats US patients and Moximed MISHA Knee System for patients in the United States.

How MISHA fits in the joint preservation menu

MISHA expands the options in between “injection and physical therapy” and “HTO or knee replacement.” For an active 50-year-old with isolated medial compartment OA and modest varus alignment, the conversation now realistically includes HTO, MISHA, unicompartmental replacement, and continued conservative management — not just the last two. The right choice depends on the alignment, the cartilage status, the patient's activity goals, the recovery timeline tolerable, and BMI. MISHA does not replace osteotomy — for patients with significant varus alignment that is itself the problem, alignment correction with HTO addresses the cause. MISHA is a complementary option for the patient whose alignment is acceptable but whose medial compartment cartilage is symptomatic, or who needs a faster recovery than HTO allows.

Combined Procedures: Osteotomy + Cartilage / MPFL / ACL / Meniscus

This is one of the strongest indications for osteotomy and one of the most under-explained ideas in joint preservation: cartilage repair done in a malaligned knee will not last. The same forces that destroyed the original cartilage will destroy the repair, often within a few years. Realignment alone does not heal damaged cartilage — but cartilage repair without realignment fails. Combining the procedures protects the repaired surface from the forces that caused the damage in the first place. The published technical and clinical literature on patellar chondral lesions has stated this directly: correcting alignment and instability is critical for the success of cartilage repair procedures, and TTO and possibly MPFL reconstruction should be performed with cartilage repair of the patella when the anatomic pathology is present.

Common combinations in Dr. Strickland's joint preservation practice:

• HTO + MACI or OATS on the medial femoral condyle — for younger patients with focal cartilage defects and varus alignment. The HTO redistributes load away from the medial compartment and protects the cartilage repair.
• DFO + MACI or OATS on the lateral femoral condyle — mirror-image logic for valgus alignment with a lateral compartment cartilage defect.
• AMZ-TTO + MPFL reconstruction for patellar instability with both bony and soft-tissue contribution — one of the most common combined patellar stabilization operations. See MPFL reconstruction with TTO — common patient questions.
• AMZ-TTO + cartilage restoration on the patella — for patellofemoral cartilage wear with maltracking. The realignment offloads the damaged facet; the cartilage repair restores the joint surface.
• Distalization-AMZ-TTO + MPFL — for patellar instability with combined patella alta and patellar maltracking.
• HTO + meniscus root repair or transplant — when a posterior meniscus root tear has accelerated medial compartment loading and the meniscus deficiency would otherwise destroy the cartilage repair.
• HTO + ACL reconstruction — in revision ACL surgery, alignment correction is sometimes part of the operative plan when chronic varus deformity has contributed to the failure of the prior reconstruction. See ACL tear surgery.

For a worked example, see the patient story Dual Tibial Osteotomy Surgeries to Get Back to Lifeguarding — a representative case of combined osteotomy work returning an active patient to a physically demanding job. For the cartilage-repair side of these combinations, see MACI cartilage repair and cartilage transplant (OATS & allograft).

Prehabilitation

Patients who walk into surgery with a strong quadriceps, full range of motion, and no effusion recover faster and meet rehabilitation milestones more reliably than patients who walk in with a stiff, weak, swollen knee. Prehabilitation focuses on:

• Quadriceps activation and strengthening — closed-chain in pain-free range, with attention to the VMO. The single most predictive factor for early post-operative recovery after osteotomy.
• Hip-stabilizer strengthening — abductors and external rotators. Particularly important for patients having TTO and possibly MPFL reconstruction.
• Range of motion — prone heel-hangs, supine wall-slides, and stationary bike. A knee that goes into surgery with full extension recovers extension faster after.
• Effusion management — elevation, compression, and load management to minimize a chronic effusion that inhibits the quadriceps.
• Smoking cessation and metabolic optimization — specific to osteotomy patients. Smoking and uncontrolled diabetes meaningfully increase the risk of osteotomy nonunion. Patients who can quit before surgery should; patients who cannot should know that the risk profile is different for them.
• Education and expectation-setting — reviewing the rehab protocol, the brace and crutch logistics, and the realistic timeline before the operation rather than after.

For osteotomy specifically, the bone-healing biology is non-negotiable. Patients who pre-habilitate well still have to wait for the bone to consolidate. Patients who skip prehabilitation have the same biological timeline, plus a longer rehabilitation runway because the muscles are starting from a worse place.

What to Expect on Surgery Day

• Arrival and pre-op — you arrive a couple of hours before surgery for intake, change into a gown, and meet the anesthesia team.
• Anesthesia — regional anesthesia (a spinal block with sedation) plus a periarticular block placed around the knee joint during surgery. The periarticular block helps reduce post-operative pain and is part of an opioid-sparing protocol.
• Surgery — AMZ-TTO or distalization TTO typically takes 1 to 1.5 hours; HTO and DFO 1.5 to 2 hours; combined operations (TTO plus MPFL, HTO plus cartilage repair) longer; revision TTO variable based on prior anatomy. MISHA implantation is faster than osteotomy because there is no bone cut.
• Recovery room — you wake up in a hinged knee brace locked in extension for osteotomy patients, with the leg numb from the regional block.
• Going home — for many primary osteotomies and for MISHA, patients go home the same day or after a short observation stay; complex combined operations may include a single overnight stay. You go home with the brace, crutches, ice, prescribed medications, and clear written instructions. A responsible adult must drive you home.
• First 48 hours — ice, elevation, prescribed pain medications, and gentle motion as instructed. The block typically wears off over 12 to 24 hours; weight-bearing for osteotomy is touch-down only with the brace and crutches.

Recovery Timeline

Bone healing dictates the timeline for osteotomy and is not negotiable, regardless of how good the leg feels at six weeks. Osteotomy recovery is meaningfully longer than soft-tissue surgery because the bone has to consolidate at the cut site. MISHA recovery is faster because there is no bone cut.

Concurrent procedures — cartilage repair (MACI, OATS, allograft), MPFL reconstruction, ACL reconstruction, meniscus repair or transplant — extend the recovery timeline according to the longer-recovery procedure. The cartilage protocol with continuous passive motion drives the early phases of MACI plus osteotomy; the ACL protocol drives the early phases of HTO plus revision ACL.

Risks of Osteotomy

Osteotomy is well-established and durable when patient selection is right, but no surgery is risk-free, and osteotomy in particular has bone-related risks not present in soft-tissue surgery. Risks reviewed at consultation include:

• Nonunion — the bone does not heal at the osteotomy site within the expected window. Risk is meaningfully elevated by smoking, uncontrolled diabetes, and certain bone-quality factors. Nonunion may require additional surgery to add bone graft, change fixation, or both.
• Hardware irritation — the locking plate (HTO, DFO) or cortical screws (TTO) are placed beneath the skin and soft tissue. A meaningful minority of patients have symptomatic hardware that warrants removal after the bone has healed (typically after 6 months).
• Malunion — the bone heals in a position different from what was planned. Less common than nonunion but a recognized possibility.
• Neurovascular injury — the popliteal vessels and the common peroneal nerve sit close to the osteotomy site. Direct injury is uncommon; transient stretch or compression neuropraxia is more common, particularly during HTO or DFO with significant correction.
• DVT or pulmonary embolism — the immobilization and weight bearing restrictions after osteotomy are meaningful; prophylaxis is individualized.
• Iatrogenic patella baja — more common with distalization TTO or when there is quad shut down. Bringing the patella too low produces a kneecap that impinges in flexion. Pre-operative planning of the exact distalization distance minimizes this risk.
• Fragment migration — specific to TTO. The osteotomized tubercle moves away from the planned position before the bone heals. Rare but recognized.
• Persistent pain — particularly when there were multiple pain generators that were not all addressed. This is one of the reasons concurrent cartilage repair, MPFL reconstruction, or meniscus surgery is important when those problems are part of the picture.
• Infection — uncommon but possible.
• Anesthesia-related risks — nausea, rare allergic reactions, nerve damage or irritation from the block.
• Wound healing issues — reaction or allergy to absorbable sutures, skin healing issues, or superficial infection (usually treated with wound care; in rare cases requiring revision of the scar).
• Need for additional surgery — for hardware removal, nonunion management, or revision osteotomy.
• Eventual progression to joint replacement — osteotomy delays replacement; it does not prevent it indefinitely. A prior osteotomy is a known variable for the replacement surgeon, but does not preclude a later replacement when one becomes appropriate. Outcomes are not a permanent fix; the years of preserved native-joint function are the win.

The single biggest predictor of a good outcome is patient selection — the right operation in the right patient who can do the rehab. The second is patient adherence to the bone-healing timeline rather than rushing weight-bearing or activity.

Common Patient Concerns

The friction-log: the four concerns we hear most often from patients considering joint preservation surgery, with honest answers.

Insurance and Cost

Joint preservation surgery — AMZ-TTO, distalization TTO, HTO, DFO, revision TTO, MISHA implantation, and concurrent cartilage repair, MPFL reconstruction, ACL reconstruction, or meniscus surgery — is covered by most major commercial insurance plans, Medicare, and many self-funded and union plans when medical-necessity criteria are met. Coverage and cost specifics:

• Pre-authorization is required for most procedures, particularly for combined operations. The criteria typically include documentation of failed conservative care, imaging-confirmed alignment or cartilage findings, and an appropriate operative plan.
• MISHA is FDA-approved and is increasingly covered; pre-authorization specifics depend on the plan and on the documentation of medical necessity.
• Out-of-pocket cost depends on the plan deductible, coinsurance, and in-network or out-of-network status of the surgeon, the facility (HSS or affiliated outpatient surgery center), and the anesthesia group.
• Concurrent procedures — cartilage repair, MPFL, ACL, or meniscus surgery performed at the same operation — may add to the bundled or itemized billing depending on the plan.
• Hardware removal, if needed later for symptomatic plates or screws, is a separate operation and is similarly covered when medically necessary.

Before surgery, our office verifies your benefits, obtains pre-authorization where required, and reviews the estimated out-of-pocket cost with you. For benefits verification or to discuss self-pay arrangements, call us at (646) 960-7227 or contact the office.

Patient Outcomes

Three patient stories that illustrate what joint preservation surgery looks like in practice:

Paul — arthroscopy, BMAC, and the MISHA Knee System. A marathon coach told by two doctors to stop running because of arthritis. Dr. Strickland offered a regenerative approach: arthroscopy plus bone marrow aspirate concentrate (BMAC) for one knee, and the MISHA Knee System for the other. He is back to running and all sports with no restrictions. The full story is at Paul's success story; the video is below.

Peyton's tibial tubercle osteotomy. A representative TTO patient case detailed in Peyton's Tibial Tubercle Osteotomy. The case illustrates the diagnosis-to-surgery-to-recovery arc for a young active patient with patellar maltracking treated with TTO, including the imaging that drove the operative plan, the surgery itself, and the rehabilitation timeline.

Dual tibial osteotomies and a return to lifeguarding. The patient story Dual Tibial Osteotomy Surgeries to Get Back to Lifeguarding describes a patient who underwent staged tibial osteotomies and returned to a physically demanding job. The case demonstrates that joint preservation in the right patient does not just delay replacement — it preserves the function the patient cared about in the first place.

Outcomes vary by procedure, patient, alignment severity, cartilage status, and adherence to rehabilitation. The published joint preservation literature is broadly favorable in well-selected patients, but no surgical intervention guarantees a permanent result and durability of the alignment correction depends on patient factors including activity, weight, and the presence or absence of cartilage damage at the time of surgery. The clinical context above is grounded in the patient cases on this site; longer-term outcomes data on osteotomy is reported in the broader orthopedic literature.

When to Seek a Sub-Specialty Second Opinion

Joint preservation is one of Dr. Strickland's primary clinical areas. She performs the full menu of preservation procedures at HSS, has published cadaveric biomechanical research on AMZ-TTO, has presented HSS Grand Rounds on revision TTO, evaluates MISHA candidacy through early adoption of this new procedure and by serving on their advisory board, and routinely combines osteotomy with cartilage repair, MPFL reconstruction, ACL reconstruction, and meniscus surgery when concurrent pathology demands it.

A sub-specialty second opinion is particularly worth seeking when:

• You have been told you need a partial or total knee replacement at a younger age and want to evaluate joint-preserving alternatives.
• You have a prior failed or symptomatic tibial tubercle osteotomy and need revision — revision osteotomy materially benefits from a high-volume sub-specialist.
• You have combined cartilage damage and malalignment and want a clear plan for combined cartilage repair plus realignment osteotomy.
• You have combined patellar instability and patellar cartilage damage and want a sub-specialty plan that addresses both the bony anatomy (TTO) and the soft tissue (MPFL).
• You have patella alta with recurrent instability or cartilage wear and need a distalization osteotomy planned to avoid iatrogenic patella baja.
• You have been told MISHA might be an option but want a second opinion on candidacy at a high-volume center with direct trial-era experience with the implant.
• You have failed prior cartilage repair in the setting of malalignment or instability that was not addressed at the index operation.
• You are active and want to preserve native-joint function rather than commit to an implant in your 30s, 40s, or 50s.

Joint preservation decisions are complex because the right operation depends on alignment, cartilage status, ligament status, meniscus status, prior surgery, age, BMI, and patient activity goals. Two patients with apparently similar imaging can end up with different operations because of these contextual factors. A sub-specialty second opinion does not always change the recommendation — but it does ensure the recommendation is built on the right framework.

Access & Office Locations

Dr. Strickland sees joint preservation patients at two offices, both of which work with patients traveling in from outside the immediate area:

• New York City (primary): Hospital for Special Surgery, East River Professional Building, 523 East 72nd Street, 2nd Floor, New York, NY 10021. Upper East Side, accessible from Manhattan, the outer boroughs, Long Island, Westchester, and northern New Jersey via the Queensboro and Triboro bridges and the FDR Drive. Phone: (646) 960-7227.
• Stamford, CT (satellite): Stamford Chelsea Piers, 1 Blachley Road, Stamford, CT 06902 — convenient for patients in Fairfield County, lower Connecticut, and Westchester.

Many patients travel to New York for joint preservation sub-specialty care — particularly for revision TTO, complex combined cartilage-plus-osteotomy cases, MISHA candidacy evaluations, and second opinions on early replacement recommendations. Surgery is performed at HSS. We coordinate consultation, imaging review, and surgery scheduling to minimize travel for out-of-state patients.

Frequently Asked Questions

Source Grounding & Published Research

This page is grounded in Dr. Strickland's published commentary, cadaveric biomechanical research, technical case reports, HSS Grand Rounds presentations, and patient education on joint preservation surgery. Selected references:

Related Specialty Care

For the cartilage-repair side of joint preservation — commonly combined with osteotomy — see MACI cartilage repair and cartilage transplant (OATS & osteochondral allograft). For the soft-tissue side of patellar realignment, see MPFL reconstruction surgery. For the broader patellar instability picture (often combined with AMZ-TTO), see patellar instability. For patellofemoral pain or arthritis, see patellar pain and patellofemoral arthritis. For meniscus-deficient compartments where root repair or transplant is part of the joint preservation plan, see meniscal tear and torn meniscus. For revision ACL where alignment correction is part of the plan, see ACL tear surgery. For multi-compartment knee arthritis where joint preservation is no longer feasible, see knee arthritis. For complex anatomy where computer-guided planning is helpful, see Mako robotic-assisted surgery.

For Dr. Strickland's published research and editorial commentary on joint preservation, the source-grounding table above lists the references used on this page; for the broader publication record, see research & publications.