Distal Femoral Varus Osteotomy: Unloading the Lateral Compartment: Long-term Follow-up of 45 Medial Closing Wedge Osteotomies

Abstract

Distal femoral medial closing wedge osteotomy is useful for mechanical axis realignment to unload the lateral compartment of the valgus knee. The primary indication for unloading the lateral compartment is lateral unicompartmental osteoarthritis. Alternative treatment options include lateral unicompartment or total knee arthroplasty (TKA). Prerequisites for the osteotomy include a 90° arc of motion, age younger than 60 years, and an active patient capable of an extensive period of rehabilitation. Surgery is carried out through a midline skin incision and uses a subvastus approach. The medial femoral closing wedge osteotomy is fixed with a 90° dynamic compression blade plate. A critical technical point is the need to insert the blade plate parallel to the joint line. The right angle plate corrects the tibialfemoral angle to 0°. A benefit of the closing wedge over an opening wedge osteotomy is reduced risk of nonunion. Survivorship and functional outcome of 41 patients with 45 distal femoral varus osteotomies at a mean follow-up of 13.3 years were retrospectively analyzed. Survivorship at 10, 15, and 20 years was 90%, 79%, and 21.5% respectively. Mean Modified Knee Society Score was 36.1 preoperatively, 74.4 at 1-year postoperatively, and 60.5 at last follow-up. Distal femoral varus osteotomy is effective at unloading the lateral compartment in unicompartmental arthritis in the valgus knee. It may be indicated in the young, high activity demand, and overweight patient. By 20 years after the osteotomy most patients require conversion to TKA.

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5 Years

“…Sternheim et al [17] recently reported on the outcome of 45 knees treated with medial closing-wedge distal femoral osteotomy for lateral compartment arthritis. Survivorship at 10, 15, and 20 years was 90%, 79%, and 21.5%, respectively.…”

Femoral osteotomies for the valgus knee

“…Good results are reported for closing wedge DFOs at 10 years of follow up with survival rates ranging between 64% (42) and 89.9% (43 (9) reported survival rate of 52.5% at the same follow-up. A recent review confirm the significantly increasing of failure rates in follow-up longer than 10 years (7).…”

Varus-Producing Lateral Distal Femoral Opening-Wedge Osteotomy

“…Several authors have since reproduced excellent results using the technique of Healy et al in appropriately selected patients with unicompartmental disease. 11,13,17,18 With its proven track record, the indications for this procedure have been expanding in recent years. Several authors have advocated performing a DFO in the setting of valgus deformity with associated MCL incompetence 5,6 ; however, there remains a paucity of literature regarding this topic.…”

“…[2][3][4] Recently, the indications for varus-producing DFOs have expanded to include the treatment of valgus malalignment in the setting of central or medial ligamentous instability or incompetence. [5][6][7][8][9][10][11][12][13][14] This is of particular importance and utility because several authors have also reported that healing of both the native and reconstructed medial collateral ligament (MCL) is impaired with persistent valgus deformity at the knee. 6 For this reason, many surgeons now choose to perform a DFO to correct the valgus deformity at the knee not only in the setting of isolated lateral compartment pathology but also in the setting of medial ligamentous incompetence.…”