Abstract
Background: Osteotomies around the knee aim to correct varus or valgus malalignment and improve biomechanics. However, little is known about their effect on knee phenotypes, as defined by the Coronal-Plane-Alignment-of-the-Knee (CPAK) and Hirschmann's functional classification. This study evaluated pre- and postoperative phenotypes in patients undergoing high-tibial-osteotomy (HTO) or distal-femoral-osteotomy (DFO). Methods: We retrospectively analysed 214 osteotomies around the knee (HTO: 145; DFO: 69) of 188 patients from our institutional registry. Radiographic parameters were measured using a validated artificial intelligence software, with phenotypes classified by CPAK and Hirschmann classification. Preoperative osteotomy planning was compared to postoperative alignment. Regression was used to assess the influence of demographic and radiographic factors. Results: CPAK types changed in 95.3% of cases. Medial opening HTOs most frequently shifted from CPAK type I (73.8%) to VI (42.3%), while medial closing DFOs transitioned from type III (81.5%) to V (24.1%). Concordance between planned and achieved CPAK types was highest for types III, IV, and V. Postoperative angles were generally smaller than planned for joint-line-obliquity (JLO), lateral-distal-femur-angle, and medial-proximal-tibial-angle (p < 0.001). Neutral JLO was restored in only 48.1%. Preoperative phenotypes NEUmLDFA0° (40.1%) and VARmMPTA3° (32.3%) were most common, while postoperative phenotypes included VALmLDFA3° (52.4%) and VALmMPTA3° (37.7%). Age, sex, and BMI significantly influenced alignment outcomes. Conclusions: Postoperative CPAK classifications shifted significantly across all osteotomy types, with minimal retention of preoperative types. Although most procedures achieved correction within the target HKA range, restoration of a neutral JLO was observed in only half of the cases, emphasizing the importance of phenotype-specific planning and highlight potential limitations of CPAK classification.