Management of Symptomatic Genu Recurvatum: Biomechanical Rationale, Etiology-Based Treatment Algorithm, and a Surgical Technical Blueprint

Symptomatic genu recurvatum is an uncommon sagittal-plane knee deformity associated with pathological hyperextension, pain, instability, gait disturbance, and functional limitation. Its heterogeneous causes and limited clinical evidence complicate treatment selection. This narrative review summarizes current concepts in biomechanics, etiologic classification, diagnostic evaluation, and management, with emphasis on posterior tibial slope (PTS) and slope-correcting proximal tibial osteotomy. Clinically relevant literature on genu recurvatum, sagittal knee alignment, osteotomy, and ligamentous instability was integrated with an illustrative previously reported case to provide a surgical technical blueprint. The available evidence supports an etiology-based approach. Reduced or reversed PTS is an important osseous contributor to pathological hyperextension, whereas soft-tissue, neuromuscular, and combined deformities require different strategies. In selected patients with osseous recurvatum and intact ligamentous restraints, anterior opening-wedge proximal tibial osteotomy can restore posterior slope and sagittal alignment. Critical technical steps include reproducible radiographic planning, fluoroscopically controlled K-wire placement, progressive posterior osteotomy completion, preservation of the posterior cortical hinge, gradual wedge opening, and stable fixation. An etiology-based diagnostic and treatment algorithm may facilitate individualized decision-making while avoiding unnecessary or incomplete procedures.