Factors Associated With Distal Femoral Osteotomy Survivorship: Data From the California Office of Statewide Health Planning and Development (OSHPD) Registry

Abstract

Background: Malalignment of the lower extremity can lead to early functional impairment and degenerative changes. Distal femoral osteotomy (DFO) can be performed with arthroscopic surgery to correct lower extremity malalignment while addressing intra-articular abnormalities or to help patients with knee osteoarthritis (OA) changes due to alignment deformities. Purpose: To examine survivorship after DFO and identify the predictors for failure. Study Design: Case series; Level of evidence, 4. Methods: Data from the California Office of Statewide Health Planning and Development, a statewide discharge database, were utilized to identify patients between the ages of 18 and 40 years who underwent DFO from 2000 to 2014. Patients with a history of lower extremity trauma, infectious arthritis, rheumatological disease, skeletal dysplasia, congenital deformities, malignancy, or concurrent arthroplasty were excluded. Failure was defined as conversion to total or unicompartmental knee arthroplasty, and the identified cohort was stratified based on whether they went on to fail. Age, sex, race, diagnoses, concurrent procedures, and comorbidities were recorded for each admission. Statistically significant differences between patients who required arthroplasty and those who did not were identified using the Student t test for continuous variables and a chi-square test for categorical variables. Kaplan-Meier survivorship curves were constructed to estimate 5- and 10-year survival rates. A Cox proportional hazards model was used to analyze the risk for conversion to arthroplasty. Results: A total of 420 procedures were included for analysis. Overall, 53 knees were converted to arthroplasty. The mean follow-up time was 4.8 years (range, 0.0-14.7 years). The 5-year survivorship was 90.2% (range, 85.7%-93.4%), and the 10-year survivorship was 73.2% (range, 64.7%-79.9%). The mean time to failure was 5.9 years (range, 0.4-13.9 years). Survivorship significantly decreased with increasing age ( P = .004). Hypertension and a primary diagnosis of osteoarthrosis were significant risk factors for conversion to arthroplasty (odds ratio [OR], 3.12 [95% CI, 1.38-7.03]; P = .006, and OR, 2.42 [95% CI, 1.02-5.77]; P = .045, respectively), along with a primary diagnosis of traumatic arthropathy (OR, 10.19 [95% CI, 1.71-60.65]; P = .01) and a comorbid diagnosis of asthma (OR, 2.88 [95% CI, 1.23-6.78]; P = .02). Patients with Medicaid were less likely (OR, 0.11 [95% CI, 0.01-0.88]; P = .04) to undergo arthroplasty compared with patients with private insurance, while patients with workers’ compensation were 3.1 times more likely (OR, 3.08 [95% CI, 1.21-7.82]; P = .02). Conclusion: Older age was an independent risk factor for conversion to arthroplasty after DFO in patients ≥18 years but ≤60 years. Hypertension, asthma, and a diagnosis of osteoarthrosis or traumatic arthropathy at the time of surgery were predictors associated with failure, reinforcing the need for careful patient selection. The high survivorship rate of DFO in this analysis supports this procedure as a reasonable alternative to arthroplasty in younger patients with valgus deformities about the knee and symptomatic unicompartmental OA.

Complications after high tibial osteotomy and distal femoral osteotomy are associated with increasing medical comorbidities and tobacco use

“…For each increase in year, the risk of TKA increased 7% in the DFO cohort, while in the HTO cohort, age greater than 40 conferred a 5.0 times higher risk of TKA (95% CI [2.59, 10.9]]). These findings are supported by prior survival analyses, in which older age was associated with higher conversion to TKA in both HTO and DFO [22, 31], and support older age as a relative contraindication to these osteotomies. In the both HTO and DFO cohorts, younger age was associated with increased risk of subsequent arthroscopy, both with and without cartilage procedures.…”

“…When considering survival free of any reoperation, a large study of UKAs and TKAs found a 93% and 96% survival free of reoperation, respectively [20], suggesting that arthroplasties carry a lower risk of reoperation than joint-sparing procedures. Several survival analyses of HTO and DFO have been published in the literature, with recent studies inding an 80% 5-year survival rate for HTO and a 90.2% 5-year survival rate for DFO [22,31]. The present study provides an earlier time point and demonstrates that in the short term, HTO and DFO rarely require revision to arthroplasty.…”

“…High tibial osteotomies (HTOs) and distal femoral osteotomies (DFOs) have been used to address varus and valgus malalignment, respectively, in the setting of unicompartmental arthritis and other soft tissue injuries, including ligamentous insufficiency, meniscus tears, and isolated cartilage defects [2, 19, 26, 33]. For the treatment of unicompartmental arthritis, osteotomies have demonstrated good efficacy, with postoperative 5‐year survival from arthroplasty rates of 78–93% for HTO and 74–88% for DFO [1, 4, 22, 31]. While utilization rates of HTO and DFO have declined in recent years in favor of unicompartmental knee arthroplasty (UKA) [28], osteotomies demonstrate similar efficacy and long‐term survival rates to UKA [1].…”

Return to sport following distal femur osteotomy: a systematic review

“…In particular, predictors associated with the failure of this technique are advanced age, hypertension, asthma, a diagnosis of osteoarthrosis, or traumatic arthropathy at the time of surgery. 27 Furthermore, the medium-term results of TKA after KO are comparable to arthroplasty performed as a primary procedure. Still, crucial aspects of achieving satisfactory results are proper soft tissue balance and correct mechanical axis.…”

Lateral Opening-Wedge Distal Femoral Osteotomy Made Easy: Tips and Tricks

“… 6 Risks for complications or lower survivorship in the literature include smoking, concomitant cartilage or ligament procedures, surgical indication for arthritis, and other medical conditions. 6 , 7 One of the most common complications of a distal femoral osteotomy is symptomatic hardware. 5 , 8 , 9 The authors aim to limit this complication by their plate-positioning tips.…”