Distal Femoral Osteotomy in a 34-Year-Old Female Runner: 5 Pearls - - PowerPoint PPT Presentation

Distal Femoral Osteotomy in a 34-Year-Old Female Runner: 5 Pearls for Success

Anil Ranawat, MD Hospital for Special Surgery New York, NY

HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. ANIL RANAWAT, MD Disclosure: I DO have a financial relationship with Smith and Nephew, Stryker Mako, Conformis, Elesevier and Arthrex

5 Pearls for Success

• 1. Proper Indications/templating
• 2. Surgical Technique
• 3. Concomitant Procedures

– Meniscal, OC allo, MCL

• 4. Post-Op Care

– Weight-Bearing / Rehab – DVT Prophylaxis – Meds

• 5. Outcomes

3

• 1. Proper Indications
• Functionally active
• LLC
• Valgus alignment
• <10° mechanical axis
• LDFA <87°

 i.e. deformity is in

lateral femoral condyle

4

• 1. Proper Templating
• Goal for correction is

not Fujisawa point (63%)?

• Under-correct more

than varus knee?

• I always under-

correct for chondral/cartilage procedures

5

• 1. Relative Contra-Indications
• Large deformity  Consider

ICBG

• Smoker  Consider medial

closing wedge DFO

• Mainly posterior wear (flexion

disease) Consider Lateral Tibial Opening Wedge

 (i.e. addressing flexion and

extension gaps)

6

• 2. Surgical Techniques
• Lateral approach, protect posterior

structures

• Oscillating saw blade

 Trajectory of the guide pin (1cm proximal

to medial epicondyle)

• Thin osteotomes - 1cm short
• Greenstick is more common than

HTO

• Obtain templated correction and

check

• 2. Surgical Techniques
• BG prior to plate fixation (use

ICBG if >10mm)

• Place plate and distal locking

screws

 Confirm proximal plate in on bone

• Oblique proximal screw for

“Compression plating”

• Place proximal locking screws
• Drain and close fascia

Title of Presentation Here 8

• 3. Concomitant Procedures
• Like HTO, DFO is

versatile procedure

 Meniscal allograft  OC allograft  MCL insufficiency

• Meniscal or OC allograft

I do first, then DFO

• MCL, I do DFO first

Title of Presentation Here 9

• 3. Concomitant Procedures
• Case example

 22 y/o competitive cyclist  s/p ORIF tibia and MCL

repair

• Medial joint opening,

Lateral compartment wear

• Valgus alignment
• Plan DFO, MCL recon w/

allograft

Title of Presentation Here 10

KB- R DFO

4. Post-Op Care (not like HTO)

• Higher non/delayed union

rate

 Hold CPM for one week/ use

brace (longer lever arm)

 30-50% flat foot for 4-6

weeks, then WBAT

 Always Ca/Vit D and bone

stimulator, no NSAIDs

• Higher DVT rate: use boots

and chemical prophylaxis

Title of Presentation Here 12

• 5. Understand Outcomes
• Harder to get and more

unsure what is desired correction

• OW DFO and CW DFO

have simialr results

• High Incidence of ROH
• May delay TKA

Title of Presentation Here 13

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

Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Clinical Orthopedic Related Research. 2015

• Lateral opening-wedge DFO was less accurate in

correction of valgus deformity than expected

• The procedure was associated with improved

knee pain and function scores.

• Achieving our desired correction of ± 3° from

neutral alignment was clinically difficult

Title of Presentation Here 14

Opening wedge distal femoral varus

• steotomy for lateral compartment
• steoarthritis in the valgus knee.

Saithna A, Kundra R, Getgood A, Spalding T. Knee. 2014.

• Eighteen patients underwent osteotomy surgery

(21 knees) with the aim of mechanical axis to 48- 50% from medial to lateral

• Cumulative survival of opening wedge DFVO is

comparable with that reported in closing wedge

• DFVO is a technically demanding procedure and

re-operation, particularly for removal of metalwork, is common

Title of Presentation Here 15

Distal femoral varus osteotomy combined with tibial plateau fresh osteochondral allograft for post- traumatic osteoarthritis of the knee.

Drexler M, Gross A, Dwyer T. Knee Surg Sports Traumatol Arthrosc. 2015

• The survivorship for distal femoral varus
• steotomy with fresh osteochondral allograft

following was 88.9 ± 4.6 % at 10 years, 71.4 ± 18.1 % at 15 years, and 23.8 ± 11.1 % at 20 years.

• Good or excellent clinical outcomes and

significantly delays the need for TKA in most patients.

Title of Presentation Here 16

Why I love OW DFO?

• Not the same as an HTO
• Versatile BUT not as much as

HTO

• More complications
• Reproducible technique

(easier than CW DFO) Should be a tool in armentarium

• f all knee surgeons!

Final Words….

as always goes to my father, ……



• Dr. C. S. Ranawat,

“The eyes only see what the mind knows”

Thank You!