Working Diagnosis:
1. Severe left lateral compartment knee osteoarthritis with valgus deformity. 2. Relative energy deficiency in sport (RED-S)

Treatment:
She underwent a left distal femoral osteotomy with plate fixation and concurrent left knee ACL revision surgery followed by physical therapy.

Outcome:
She is currently in physical therapy. Her goal is to return to running. Our goal is to address her bone health, nutritional status and overtraining with an additional goal of preserving her joint for as long as possible given her young age. She has been reluctant to engage in discussions regarding her RED-S.

Author's Comments:
The patient has early advanced OA at the age of 28 due to a combination of her previous ACL tear and interim overtraining with RED-S. Because of her severe joint space narrowing with weight-bearing, she was not a candidate for a meniscal transplant. Her only remaining option, apart from arthroplasty, given her valgus deformity was to have an osteotomy to correct her alignment along with procedures to address her ACL. This case illustrates potential risks of overtraining after ACL injury and brings to question the role RED-S has in graft healing and development of accelerated arthritis. It also addresses criteria for meniscal transplant and use of femoral osteotomy for realignment.

Editor's Comments:
Excellent case illustrating the complex nature of a challenging orthopedic injury which is intimately related to both psychological and behavioral issues. These patients are challenging and developing a therapeutic relationship is often the way to get them to be ready to address the complexities of RED-S. I'd highly recommend including behavioral health (can "sell" it to the patient as sports psychologist to get buy in) as well as a sports dietician.

References:
Cameron J, et al. "Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement and Survivorship at 5 years." Clinical Orthopedics and Related Research 473 (2015): 2009-15.
Hergan D, et al. "Systematic Review: Meniscal Allograft Transplantation." Arthroscopy: The Journal of Arthroscopic and Related Surgery 27.1 (2011): 101-112.
Mountjoy M, Sundgot-Borgen J, Burke L, et al. "The IOC consensus statement: beyond the Female Athlete Triad - Relative Energy Deficiency in Sport (RED-S)." Br J Sports Med 2014; 48: 491-497.

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