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 8 Title of Presentation Here

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 9 Title of Presentation Here

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 10 Title of Presentation Here

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 12 Title of Presentation Here

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 13 Title of Presentation Here

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 14 Title of Presentation Here

Opening wedge distal femoral varus osteotomy for lateral compartment osteoarthritis 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 15 Title of Presentation Here

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 osteotomy 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. 16 Title of Presentation Here

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 of 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!