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Distal femoral osteotomy

80 citationsUpdated Oct 2026
Illustration: knee

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Distal femoral osteotomy is an acceptable surgical option for young patients with severe unicompartmental knee osteoarthritis and malalignment [2]. The ideal candidates for distal femoral varus-producing osteotomy are young and active individuals with isolated lateral compartment arthritis and valgus malalignment [10]. This procedure serves as a well-described treatment for valgus malalignment associated with various underlying conditions, including isolated lateral compartment osteoarthritis [11]. By reliably correcting valgus mechanical alignment, the procedure decreases pain and increases function in patients with lateral compartment disease [12]. It remains a good alternative for treating lateral tibiofemoral osteoarthritis associated with a valgus knee [14].

The lateral opening wedge distal femoral osteotomy is a reproducible technique for limb alignment correction in patients with valgus malalignment [5]. It remains a versatile and reliable option for addressing limb malalignment in the young population that may want to preserve function and higher activity levels over a period of 10 or more years [5]. Both lateral closing wedge distal femoral osteotomy (LCWDFO) and medial closing wedge distal femoral osteotomy (MCWDFO) seem safe and effective surgical interventions for improving coronal plane deformity about the knee [21]. Coronal and rotational deformities of the femur can be accurately corrected simultaneously by a distal femoral osteotomy utilizing patient-specific instruments [3]. A preoperative calculated angle for single cut derotational osteotomy at the distal femur leads to a clinically precise post-operative result on torsion and frontal alignment when using this approach [16].

Patients with a decreased femoral trochlea axial orientation can have better surgical outcomes after correction by derotational distal femur osteotomy compared to isolated medial patellofemoral ligament reconstruction [8]. A positive malalignment sign serves as evidence for femoral derotation osteotomy [24]. The indication for concomitant tibial tubercle osteotomy should be individualized according to each patient's specific anatomical and clinical characteristics [37]. Lateral opening wedge distal femoral osteotomy has no effect on leg length [6]. While lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, the procedure was associated with improved knee pain and function scores [7]. Distal femoral opening-wedge osteotomy for lateral knee osteoarthritis resulted in good functional recovery after 1 year and favourable midterm results [13]. Performed in a young and active population, the procedure results in high return to sport rates and continuous sports participation even 7 years after the procedure [4]. The reversed Miniaci method is effective and reliable for planning distal femoral osteotomies [9]. By following specific tips, a successful lateral opening-wedge distal femoral osteotomy may be performed safely, effectively, and according to plan [1]. The procedure utilizes an osteochondral allograft to restore the integrity of the femoral condyle and a lateral opening wedge distal femoral osteotomy to correct femoral-based valgus deformity [18]. A combined distal femoral osteotomy and lateral meniscus allograft transplant represents a good option for younger patients looking to avoid knee arthroplasty, provided patient selection and preoperative counseling are of the utmost importance [26].

Anatomy & Pathophysiology

Osseous Anatomy

The distal femur exhibits distinct condylar morphology, with the medial femoral condyle being larger and projecting farther posteriorly and distally than the lateral condyle [70]. Conversely, the lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction [70]. The trochlear groove separates the femoral condyles anteriorly and constitutes the patellofemoral articulation [70]. Just distal to the intercondylar notch, the sulcus terminalis appears as a small ridge on the lateral femoral condyle, separating the patellofemoral and tibiofemoral articular surfaces [70]. This transverse ridge extends from the oblique facets of the femoral trochlea and is deeper on the lateral condyle than on the medial condyle [84]. The intercondylar notch, which is of variable width, serves as the attachment site for the cruciate ligaments [70].

Key proximal landmarks include the medial epicondyle, which is the most anterior and distal osseous prominence of the distal femur [70]. The adductor tubercle lies proximal and posterior to the medial epicondyle, while the gastrocnemius tubercle is located slightly distal and posterior to the adductor tubercle [70].

The tibial articular surface slopes 7° to 10° in the sagittal plane [70]. The medial tibial plateau is larger than the lateral plateau and is concave in both frontal and sagittal planes [70]. In contrast, the lateral tibial plateau is smaller, more circular, concave in the frontal plane, and convex in the sagittal plane [70]. The posterior slope of the medial tibial plateau averages 10.7°, while the lateral plateau averages 7.2° [84]. The tibial tuberosity, the attachment site for the patellar tendon, is typically located in the midline anteriorly but may be slightly lateral [70]. Gerdy’s tubercle, the insertion site of the iliotibial band, is located 2 to 3 cm lateral to the tibial tubercle on the proximal tibia [70]. The fibular head is located a mean of 1.5 cm distal to the joint line, with a range of 6 to 32 mm [84].

The patella is the largest sesamoid bone in the body, averaging 2.5 cm in thickness [70]. Its articular surface contains a vertical, central ridge that separates the broader lateral facet from the medial facet, along with a smaller, more medial facet known as the odd facet [70]. The patella possesses three facets: lateral, medial, and odd [84]. In Wiberg Type II patellar morphology, the medial facet is smaller and one half the size of the lateral facet [84]. The lateral trochlear facet resists lateral subluxation of the patella [84].

Ligamentous Anatomy

The anterior cruciate ligament (ACL) travels from the medial border of the lateral femoral condyle to its insertion site anterolateral to the medial tibial spine [46]. It prevents anterior translation and rotation of the tibia on the femur [46]. The ACL is an intra-articular ligament that is technically extrasynovial, as it is surrounded by synovium [82]. It is composed of 90% type I collagen and 10% type III collagen [70]. The mean length of the ACL is 33 mm, with a mean midsubstance width of 11 mm [70]. Alternatively, the ACL has a variable length of 22 to 41 mm and a width of 7 to 12 mm, consistently narrowest in the midsubstance [82]. The femoral attachment is a semicircular area 20 mm long and 10 mm wide on the posteromedial aspect of the lateral femoral condyle, posterior to the lateral intercondylar ridge [70, 82]. The tibial attachment is a broad, irregular, oval-shaped area 30 mm long and 10 mm wide, located slightly medial and anterior to the midline in the anterior intercondylar fossa between the medial and lateral tibial spines [70, 82]. The tibial insertion of the ACL is 120% larger than the femoral insertion [82].

The ACL consists of two bundles named according to their tibial insertions: the anteromedial bundle and the posterolateral bundle [71]. The anteromedial bundle originates proximal to the bifurcate ridge and is tight in flexion [71]. The posterolateral bundle originates distal to the bifurcate ridge and is tight in extension [71].

The posterior cruciate ligament (PCL) runs from the lateral aspect of the medial femoral condyle to the posterior aspect of the tibia, just below the joint line [46]. It prevents posterior subluxation of the tibia on the femur [46]. The PCL has a mean length of 38 mm and a mean width of 13 mm [84]. Its femoral attachment is broad and crescent-shaped on the anterolateral medial femoral condyle, with a mean length of 30 mm and a mean width of 5 mm [84]. The PCL inserts on the anteromedial wall of the intercondylar notch [84]. The tibial insertion onto the posterior central sulcus is 10 to 15 mm distal to the joint line of the knee [84]. The PCL has anterolateral and posteromedial bundles that are codominant [71]. The anterolateral bundle is stronger and stiffer than the posteromedial bundle and is tight in knee flexion [84]. The posteromedial bundle is tight in knee extension [84].

The medial collateral ligament (MCL) has superficial and deep portions which stabilize the knee to valgus stresses [46]. The superficial MCL (proximal division) resists valgus tibial translation and tibial external rotation [71]. The deep MCL resists valgus translation and tibial internal and external rotation [71]. The posterior oblique ligament resists tibial internal rotation, especially in knee extension [71].

The lateral collateral ligament (LCL) runs from the lateral femoral condyle to the head of the fibula and is the main stabilizer against varus stress [46]. It resists varus tibial translation and tibial external rotation, especially at 30 degrees of knee flexion [71]. The popliteofibular ligament is present in 90% of knees and runs from the tendon of the popliteus muscle to the styloid on the posterior fibular head [46]. It resists tibial external rotation, especially in knee flexion, and posterior tibial displacement [71]. The popliteus tendon also resists tibial external rotation, especially in knee flexion [71]. The oblique popliteal ligament resists knee hyperextension and varus tibial translation [71].

The medial patellofemoral ligament runs from the patella near the junction of the middle and superior thirds to the medial femoral epicondyle [73]. It is more important for patellar stability than the lateral patellofemoral ligament [73]. The posteromedial corner of the knee includes the posterior oblique ligament, semimembranosus tendon and its expansions, oblique popliteal ligament, posteromedial joint capsule, and posterior horn of the medial meniscus [79]. The central portion of the posterior oblique ligament originates in the region of the adductor tubercle and inserts at the posteromedial corner of the tibia near the insertion of the direct head of the semimembranosus tendon [79]. The posteromedial capsule and posterior oblique ligament become progressively relaxed as the knee flexes, but remain tense with active contraction of the semimembranosus muscle [79].

Meniscal Anatomy

The menisci are C-shaped fibrocartilaginous disks that provide shock absorption, increase congruency between joint surfaces, enhance joint stability, and aid in distribution of synovial fluid [46]. They consist of type I collagen fibers arranged obliquely, radially, and vertically [84]. The medial meniscus is firmly attached to the joint capsule along its entire peripheral edge [46]. It has a semicircular shape that covers approximately 50% to 60% of the medial tibial plateau in adulthood [80]. The medial meniscus is crescent-shaped and attaches more anterior and posterior than the lateral meniscus [84]. The posterior horn of the medial meniscus averages 11 mm in the anterior-posterior dimension [80]. The anterior horn attaches to the tibia anterior to the ACL near the intercondylar fossa [80]. The posterior root attaches in the posterior intercondylar fossa between the lateral meniscus and PCL [80].

The lateral meniscus is attached to the anterior and posterior capsule but has a region posterolaterally where it is not firmly attached [46]. This less continuous attachment allows for greater meniscal mobility [80]. The lateral meniscus is larger than the medial meniscus and carries a greater share of the lateral compartment pressure [46]. It has a more circular C-shape with symmetric sizes of the anterior and posterior horns [80]. The lateral meniscus is circular in shape and covers a larger proportion of the tibial plateau than the medial meniscus [84]. The anterior root attaches anterior to the intercondylar eminence and just lateral to the ACL insertion site on the tibia [80, 84]. The posterior root attaches posterior to the lateral tibial spine just anterior to the medial meniscus posterior root [80]. The popliteomeniscal fascicles extend from the lateral meniscus to the posterior capsule to create the popliteal hiatus [80]. The meniscofemoral ligaments connect the posterior horn of the lateral meniscus to the medial femoral condyle [80]. The ligament of Humphrey crosses anterior to the PCL, while the ligament of Wrisberg crosses posteriorly [80].

The medial meniscus has less mobility than the lateral meniscus and is more susceptible to tearing when trapped between the femoral condyle and tibial plateau [46]. Mean lateral meniscus excursion from knee extension to flexion is 11.2 mm, compared to a mean medial meniscus excursion of 5.1 mm [80]. Vascular supply to the menisci is derived from the geniculate arteries, which penetrate into 20% to 30% of the peripheral medial meniscus and 10% to 25% of the peripheral lateral meniscus [84]. The inner one-third of the meniscus is avascular and called the white-white zone [80]. The middle zone is called the red-white zone because it has limited vasculature [80]. The back one-third is called the red-red zone because it is the most vascularized tissue region with access to blood supply through vessels arising from the geniculate arteries [80].

Vascular and Neural Anatomy

The blood supply to the knee is formed from an anastomosis around the knee derived from the descending geniculate artery, medial and lateral superior geniculate arteries, medial and lateral inferior geniculate arteries, middle geniculate artery, and anterior tibial recurrent arteries [70]. The middle geniculate artery supplies both the anterior and posterior cruciate ligaments [70]. Specifically, the middle geniculate artery is the primary blood supply to the ACL [84] and the PCL [84]. The inferior geniculate arteries pass deep to their respective collateral ligaments [70]. The blood supply of the patella is derived from the geniculate artery complex with some contribution from the anterior tibial recurrent artery and primarily exists in the middle to inferior portions of the patella [70]. The popliteal artery is near the PCL, and the distance increases with knee flexion [84].

The knee is innervated by branches of the femoral nerve (L2, L3, L4), obturator nerve (L2, L3, L4), and sciatic nerve (L4, L5, S1, S2) [70]. The largest nerve providing innervation of the intra-articular knee is the posterior articular branch of the tibial nerve [70]. This branch supplies the infrapatellar fat pad, the synovial covering over the cruciate ligaments, and the periphery of the meniscus [70]. It also provides innervation to the ACL [84] and the PCL [84]. Nerves to the cruciate ligaments contain vasomotor and pain fibers as well as mechanoreceptors that may be involved in proprioception [70]. The infrapatellar branch of the saphenous nerve arises proximal to the knee joint medially and crosses distal to the patella to innervate the skin over the region of the anterior knee and proximal tibia [70].

Biomechanics and Pathophysiology

The knee is a hinge joint that also incorporates both gliding and rolling, which are essential to its kinematics [71]. The "screw-home" mechanism involves the tibia externally rotating 5 degrees in the final 15 degrees of extension [71].

The ACL is typically subjected to peak loads of 170 N during walking and up to 500 N with running [85]. The ultimate strength of the ACL in young patients is about 1750 N [85]. The ACL fails by serial tearing at 10% to 15% elongation [85]. Sectioning the PCL increases contact pressures in the medial compartment and the patellofemoral joint [85].

Knee joint surface loads are three times body weight during level walking and up to four times body weight with stair walking [85]. The menisci help with load transmission and bear one-third to one-half body weight [85]. Removal of the menisci increases contact stresses by up to four times the load transfer to bone [85]. The quadriceps produces maximum anterior force on the tibia at 0 to 60 degrees of knee flexion [85].

The patella aids in knee extension by increasing the lever arm and stress distribution [85]. It has the thickest cartilage in the entire body and bears the greatest load [85]. The patella bears half the body weight with normal walking and seven times the body weight with squatting and jogging [85]. Patellofemoral loads are proportional to the ratio of quadriceps force to knee flexion [85]. In descending stairs, compressive force in the patellofemoral joint reaches two to three times body weight [85].

The mechanical axis of the lower extremity runs from the center of the femoral head to the center of the ankle and normally passes just medial to the medial tibial spine [85]. This axis is in 3 degrees of valgus angulation from the vertical axis [85]. The anatomic axis of the femur is in 6 degrees of valgus angulation from the mechanical axis and 9 degrees versus the vertical axis [85]. The anatomic axis of the tibia is in 2 to 3 degrees of varus angulation from the mechanical axis [85].

Osteotomy addresses both mechanical correction and the modulation of the inflammatory environment in the joint [28]. Internal tibial torsion seems profoundly responsive to correction of coronal plane deformity [29]. With more tibiofemoral angle correction, more congruence angle correction can be achieved, requiring simultaneous patellar stabilization [30]. Spontaneous corrective growth of the opposite epiphyseal plate can result in an inclination of the knee joint line even if the overall leg axis is restored [32]. Restoration of a neutral mechanical axis corrects maltracking and subluxation by decreasing lateral patellar forces [40].

Classification

Segmental Femoral Torsion Analysis: A novel classification system based on segmental femoral torsion analysis has been established for patients presenting with recurrent patellar subluxation and excessive femoral torsion [112].

Medial Cortical Hinge Fractures (Lateral Opening-Wedge): Medial cortical hinge fractures are a common finding in lateral opening-wedge distal femoral osteotomy and are categorized into three distinct types [50].

Medial Femoral Hinge Fractures (Lateral Closed-Wedge): In lateral closed-wedge distal femoral osteotomy, a medial femoral hinge fracture is defined as a fracture line extending from the end of the osteotomy that breaches the medial femoral cortex [142]. The specific types are defined by their relationship to the osteotomy line: * Type 1: The fracture extends to the medial cortex in line with the osteotomy [142]. * Type 2: The fracture breaches the medial cortex proximally to the osteotomy line [142]. * Type 3: The fracture extends distally from the osteotomy [142].

Lateral Closing Wedge Distal Femoral Osteotomy Fractures: In lateral closing wedge distal femoral osteotomy, fracture classification is based on the orientation of the fracture line relative to the osteotomy [146]. * Extension Type: A fracture in line with the osteotomy is classified as an extension type fracture [146]. * Proximal Type: Fracture lines diverting proximally of the osteotomy orientation are classified as proximal type fractures [146]. * Distal Type: Fracture lines diverting distally of the osteotomy orientation are classified as distal type fractures [146].

Clinical Presentation

Indications and Patient Selection

Distal femoral osteotomy serves as an acceptable surgical option for young patients presenting with severe unicompartmental knee osteoarthritis and malalignment [2]. In the context of valgus malalignment associated with isolated lateral compartment osteoarthritis, distal femoral varus osteotomy is a well-described treatment option [11]. This procedure, particularly when utilizing blade-plate fixation, offers a reliable method for managing lateral-compartment osteoarthritis accompanied by valgus deformity [22]. The femoral medial closing wedge osteotomy specifically targets the improvement of symptoms in lateral osteoarthritis within the valgus knee [35]. Medial closing wedge distal femoral osteotomy (MCW-DFO) proves effective for treating pathological valgus knees regardless of the specific site of the deformity [39]. Both lateral and medial closing wedge distal femoral osteotomies constitute safe and effective surgical interventions for improving coronal plane deformity about the knee [21]. Osteotomy remains a critical component of comprehensive treatment for young patients with knee pain, malalignment, and cartilage disorders, addressing both mechanical correction and the modulation of the inflammatory environment within the joint [28].

Patellofemoral Instability and Rotational Deformity

Derotational femoral osteotomy significantly reduces femoral anteversion and improves subjective knee function [20]. In patients exhibiting patellofemoral instability with associated increased femoral anteversion, derotational distal femoral osteotomy achieves a significant reduction in pain, improves subjective knee function, and provides adequate correction of both torsional and coronal alignment [55]. For patients with recurrent patellar dislocation who possess an excessive femoral anteversion angle and trochlear dysplasia, MPFL reconstruction combined with derotational distal femur osteotomy yields satisfactory clinical outcomes during follow-up [123]. Furthermore, distal femoral osteotomies improve recurrent patellar instability in patients with genu valgum [36].

Imaging and Preoperative Planning

Preoperative assessment relies on specific imaging modalities to evaluate alignment and morphology. The long limb standing view serves as the gold standard for evaluating varus-valgus alignment [34]. Computed Tomography (CT) is the gold standard for evaluating rotational malalignment, including femoral and tibial torsions [34]. EOS, a 3-D X-ray system, represents a recent addition to alignment evaluation but is often not available [34]. Regarding trochlear imaging, the gold standard is a true lateral view radiograph interpreted using Dejour's classification [34]. Dejour's types B and D, particularly in the presence of a trochlear spur or bump, are considered high-grade trochlear dysplasia [34]. The TT-TG distance threshold of 20 mm remains somewhat controversial; however, values of 15 mm on MRI are significantly abnormal, representing 2 standard deviations from the population mean [34].

Outcomes and Functional Recovery

Correction of valgus knee malalignment through distal femoral varus osteotomy reliably results in improved function and return to sport, provided that concomitant chondral, meniscal, and ligamentous pathology is addressed [58]. Lateral opening wedge distal femoral osteotomy (LOW-DFO) is an efficient procedure for managing lateral knee osteoarthritis in young patients with valgus deformity, demonstrating a good survival rate at 10 years and high patient satisfaction [59]. At 8-year follow-up, the preoperative CPAK phenotype does not affect clinical and radiological outcomes after medial closing-wedge distal femoral osteotomy in valgus knees [61].

Biomechanical and Anatomical Effects

Lateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance [17].

Investigations

Plain radiography: Plain radiographs serve as the appropriate initial imaging studies for most knee conditions, enabling assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [88]. Weight-bearing AP and lateral views assess cartilage loss from the distal femur and tibial plateau [88], while a PA (Rosenberg; flexion) view evaluates cartilage loss from the posterior femur and tibial plateau [88]. Patellofemoral views assess patellofemoral alignment (tilt/subluxation), patellar and trochlear morphology, osteochondral injury, and patellofemoral arthritis [88]. A notch view is used to assess posterior femoral cartilage, notch width, and osteophytes [88]. In the setting of osteoarthritis, radiographs may identify subchondral sclerosis, joint space narrowing, subchondral cysts, osteophytes, and joint subluxation [88]. Although radiographs can underestimate isolated chondral lesions, they may demonstrate joint space narrowing, osteophytes, sclerosis, and cysts [92]. The ability to detect subtle narrowing or an isolated chondral defect on the flexion surface may be improved with a semiflexed PA view [92].

Standing full-length AP radiographs from the hip joint to the ankle joint evaluate limb alignment and knee deformity [96]. These views identify femoral and/or tibial bone deformity, whether developmental or traumatic [96]. Long leg alignment views determine the mechanical axis [92]. If the mechanical axis traverses the involved compartment, realignment may need to be considered as an initial procedure or as an adjunct to a cartilage restorative procedure [92]. Stress radiographs help better quantify the amount of varus angulation present in cases of chronic posterolateral instability [97].

CT: Three-dimensional CT with remodeling is used for preoperative planning for reconstruction associated with dysplasia, post-trauma planning, and complex total knee arthroplasty planning [96]. Three-dimensional CT reconstructions may help with preoperative planning for multiplanar osteotomy for limb malalignment [88]. Axial plane imaging of the hip and knee can help assess the rotational alignment of components of a total knee arthroplasty in cases of patellar maltracking [88]. Preoperative radiographic imaging can be used to predict leg length change after valgus-correcting distal femoral osteotomy with high reliability [140].

MRI: MRI may identify the degree of articular cartilage injury, including chondrosis and full-thickness cartilage loss, as well as the presence of associated bone marrow edema and the location of the injury [88]. MRI can be used to evaluate articular cartilage morphology [92]. A positive malalignment sign on knee magnetic resonance imaging serves as evidence for femoral derotation osteotomy in patients with patellar dislocation [24].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections for distal femoral osteotomy.

Operative

Indications: The lateral opening wedge distal femoral osteotomy is indicated for patients with valgus malalignment who are young and wish to preserve function and higher activity levels over a period of 10 or more years [5].

Surgical Approach / Technique: Several techniques exist for distal femoral osteotomy. The lateral opening wedge technique is reproducible for limb alignment correction in valgus malalignment [5]. A medial closing-wedge distal femoral osteotomy with locking plate fixation provides a highly stable construct suitable for early weight-bearing and avoids hardware-related issues associated with lateral opening-wedge osteotomies [19]. This procedure can be performed using 3D patient-specific instrumentation in addition to a patellar osteochondral allograft transplant [63]. The supracondylar V osteotomy through a lateral approach is useful because surgical time and blood loss are minimal, and it has a short learning curve [38]. The V shape allows large correction while preserving stability, with correction obtained by lateral penetration and crushing of the cancellous bone [38]. Mediolateral translation is not necessary because no wedges are taken [38]. The posterior limb of the V is made slightly longer than the anterior limb to prevent flexion of the distal fragment [38]. Derotational distal femoral osteotomy is categorized based on the incision location into medial incision and lateral incision [41].

Implant Selection: Internal fixation with a plate offers the advantage of early mobility and rehabilitation, which may reduce patient morbidity and save time compared with correction without a plate [38]. Improvements in the TriS-MDFO, including the diamond-shaped head, more distally oriented screws, and novel compression hook, may increase the ease and safety of medial closed wedge distal femoral osteotomy [43].

Alignment / Balancing Strategy: Biomechanical analysis indicates that positioning the plate more posteriorly and avoiding distal placement during medial closing wedge distal femoral osteotomy (MCDFO) represents the biomechanically optimal strategy [15]. The most favorable outcomes were identified when the plate was placed in the most posterior and proximal position, with respect to mean stress at the lateral hinge of the distal femur [15]. A posterior and mid-height position was found to be advantageous [15]. During MCDFO, positioning the plate as posteriorly as possible while avoiding anterior placement may enhance the stability of the bone-implant construct [15]. Interfragmentary micromotion at the osteotomy site decreased consistently as the plate was positioned more posteriorly and more proximally across all tested knee flexion angles [15].

Other Considerations: Hinge fracture, nonunion, malunion, correction loss, and implant breakage are not uncommon and may necessitate additional surgical intervention, resulting in persistent pain, prolonged rehabilitation, and a substantial clinical burden for patients [15]. Concomitant medial arthroplasty (MAT) and distal femoral valgus osteotomy (DFVO) afforded a high rate of return to sport at an average of 16.9 months postoperatively, as well as a significant decrease in VAS pain scores [156]. Forty-nine percent of patients required removal of screws from the osteotomy site [31].

Complications

General Complication Rates and Risk Factors: Distal femoral osteotomy carries a higher rate of overall complications in the short and mid term compared to high tibial osteotomy [159]. A 15-year single academic institution experience reported a low rate of intraoperative complications (1.2%) but a relatively high rate of early (≤90 days) postoperative complications (42.0%) after high tibial osteotomy or distal femoral osteotomy [125]. Complications are associated with increasing medical comorbidities and tobacco use [159]. In a cohort using patient-specific instrumentation for corrective high tibial and distal femoral osteotomy, 22% (5/23) of cases had at least one related, unplanned reoperation, with a total survivorship of 91% (21/23 knees) [107]. Complication rates in a series of 71 patients treated with opening-wedge distal femoral osteotomy for lateral compartment osteoarthritis ranged from 0% to 30% [52].

Hinge Fractures and Bony Complications: Hinge fracture, nonunion, malunion, correction loss, and implant breakage are not uncommon complications of medial closing-wedge distal femoral osteotomy that may necessitate additional surgical intervention [15]. Positioning the plate more posteriorly and avoiding distal placement represents the biomechanically optimal strategy to minimize interfragmentary micromotion and stress at the lateral hinge [15]. Other listed complications for medial closing-wedge distal femoral osteotomy include neurovascular injury, nonunion (violation of lateral cortex), fracture of condyle, deep infection, failure to properly correct alignment, hematoma, and compartment syndrome [62]. In a cohort using patient-specific instrumentation, one patient sustained an intraoperative hinge fracture, specifically an intra-articular tibial plateau fracture, which was treated intraoperatively with open reduction and internal fixation [107].

Hardware and Implant Complications: Hardware removal is frequently required; 49% of patients required removal of screws from the osteotomy site in a study of patellofemoral instability in athletes [31], and six patients underwent removal of hardware in a cohort using patient-specific instrumentation [107]. A case report describes the migration of a broken screw to the knee joint after hardware failure following closing wedge distal femoral osteotomy [162]. In a study of high tibial open-wedge osteotomy with spacer plates, four implant failures (two plate breakages and two patients with screw loosening) and two delayed unions resulted in an implant-related complication rate of 10.9%, requiring revision surgery with conversion to a different fixation system [110]. Improvements in the TriS-MDFO plate, including the diamond-shaped head, more distally oriented screws, and novel compression hook, may increase the ease and safety of medial closed wedge distal femoral osteotomy [43].

Infection (PJI): In a cohort using patient-specific instrumentation for corrective osteotomy, one patient had a wound complication that required a return to the operating room for irrigation and debridement and revision closure [107]. In a study of high tibial open-wedge osteotomy with spacer plates, infection occurred in four cases (7.3%) [110]. Three of these four infection cases were treated with debridement and antibiotics, and one required septic implant removal and restabilization with an external fixator [110]. In a systematic review of derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction, no patients experienced infection postoperatively [111].

Stiffness / Arthrofibrosis: In a systematic review of derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction, the overall pooled risk of major complications was 1.3% (95% CI = 0.3%–3.0%) [111]. The most common major complication in this cohort was knee stiffness in the short term after surgery [111]. No patients experienced nonunion at the osteotomy site postoperatively [111].

Vascular and Neurological Complications: Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy for distal femoral osteotomy [153]. In a cohort using patient-specific instrumentation for corrective osteotomy, there were no neurovascular injuries [107].

Other Considerations: Tranexamic acid significantly reduces postoperative blood loss in patients undergoing distal femoral osteotomy without increasing the risk of thromboembolic complications [147]. Patients who undergo total knee arthroplasty after prior distal femoral osteotomy are at increased risk of postoperative complications and revision surgery compared to primary total knee arthroplasty patients [143]. Total knee arthroplasties after varus distal femoral osteotomy can carry an increased risk of intra-operative complications, but medium term results are comparable to arthroplasty performed as a primary intervention [157]. Ten-year survivorship free from aseptic loosening for total knee arthroplasty after distal femoral osteotomy was 95%, though there was a high complication rate secondary to problems with balancing the knee [148].

Recovery

Light activity (weeks): In a young and active population, distal femoral varus osteotomy for valgus deformity reliably affords the ability to return to work within a relatively short time period, regardless of the occupational demand level [116]. A medial closing-wedge distal femoral osteotomy with locking plate fixation affords a highly stable construct suitable for early weight-bearing [19]. Internal fixation with a plate during wedge-less V-shaped distal femoral osteotomy has the advantage of early mobility and rehabilitation, which may reduce patient morbidity and save time compared with correction without a plate [38].

Full activity (months): Undergoing isolated lateral closing wedge distal femoral osteotomy for symptomatic femoral-based varus malalignment enabled the vast majority of patients to return to sports and work along with a significant functional improvement at mid-term follow-up [120]. Lateral opening-wedge distal femoral osteotomy was associated with improved knee pain and function scores [7].

Complete recovery / outcome plateau (months): Postoperative recovery is long, with a majority of patients not reaching a functional end-point by 6 or 12 months, but further improvement was found after 12 months [69].

Other Considerations: Psychological readiness to resume sporting activities correlated with knee function and was significantly higher in patients who achieved the preoperative level of sport than in patients who did not [152].

Key Evidence

  • [L5] By following these tips, the authors believe that a successful lateral opening-wedge distal femoral osteotomy may be performed safely, effectively, and according to plan. [1] (10.1016/j.eats.2023.08.021)
  • [L4] Distal femoral osteotomy is an acceptable surgical option for the young patient with severe unicompartmental knee osteoarthritis and malalignment. [2] (10.1177/2325967114s00051)
  • [L3] Coronal and rotational deformities of the femur can accurately be corrected simultaneously by a distal femoral osteotomy utilizing patient-specific instruments. [3] (10.1177/03635465251314868)
  • [L4] Distal femoral osteotomy performed in a young and active population results in high return to sport rates and continuous sports participation even 7 years after the procedure. [4] (10.1002/ksa.70524)
  • [Paper] The lateral opening wedge distal femoral osteotomy is a reproducible technique for limb alignment correction in patients with valgus malalignment and remains a versatile and reliable option for addressing limb malalignment in the young population that may want to preserve function and higher activity levels over a period of 10 or more years. [5] (10.1016/j.eats.2016.02.037)
  • [L4] Lateral opening wedge distal femoral osteotomy has no effect on leg length. [6] (10.1007/s00167-014-3387-5)
  • [L4] Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. [7] (10.1007/s11999-014-4106-8)
  • [L3] Patients with a decreased femoral trochlea axial orientation can have better surgical outcomes after correction by derotational distal femur osteotomy compared to isolated medial patellofemoral ligament reconstruction. [8] (10.1002/ksa.12193)
  • [L4] The reversed Miniaci method is effective and reliable for planning distal femoral osteotomies. [9] (10.1016/j.otsr.2023.103697)
  • [Paper] Ideal candidates for distal femoral varus-producing osteotomy are young and active individuals with isolated lateral compartment arthritis and valgus malalignment. [10] (10.1016/j.csm.2019.02.005)
  • [L5] Distal femoral varus osteotomy is a well-described treatment option for patients with valgus malalignment associated with a variety of underlying conditions, including isolated lateral compartment osteoarthritis. [11] (10.5435/jaaos-d-16-00179)
  • [Paper] Distal femoral osteotomy can reliably correct valgus mechanical alignment, decrease pain, and increase function in patients with lateral compartment disease. [12] (10.1016/j.eats.2016.08.009)
  • [L4] Distal femoral opening-wedge osteotomy for lateral knee osteoarthritis resulted in good functional recovery after 1 year and favourable midterm results. [13] (10.1007/s00167-016-3988-2)
  • [L4] Distal femoral varus osteotomy is a good alternative for treating lateral tibiofemoral osteoarthritis associated with a valgus knee. [14] (10.1016/j.otsr.2010.04.009)
  • [L5] [15] (10.1177/23259671261469346)
  • [L5] A preoperative calculated angle for single cut derotational osteotomy at the distal femur leads to a clinically precise post-operative result on torsion and frontal alignment when using this approach. [16] (10.1186/s12891-018-2140-5)
  • [L5] Lateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance. [17] (10.1186/s12891-023-06832-w)
  • [L5] The procedure utilizes an osteochondral allograft to restore the integrity of the femoral condyle and a lateral opening wedge distal femoral osteotomy to correct femoral-based valgus deformity. [18] (10.1016/j.eats.2022.03.014)
  • [Paper] A medial closing-wedge distal femoral osteotomy with locking plate fixation affords a highly stable construct suitable for early weight-bearing and avoids hardware-related issues associated with lateral opening-wedge osteotomies. [19] (10.1016/j.eats.2021.03.013)
  • [L4] Derotational femoral osteotomy could significantly reduce femoral anteversion and improve subjective knee function. [20] (10.1002/ksa.12015)
  • [L4] Lateral closing wedge distal femoral osteotomy (LCWDFO) and medial closing wedge distal femoral osteotomy (MCWDFO) both seem safe and effective surgical interventions for improving coronal plane deformity about the knee. [21] (10.5435/jaaosglobal-d-24-00139)
  • [L4] Distal femoral varus osteotomy with blade-plate fixation can be a reliable procedure for the treatment of lateral-compartment osteoarthritis of the knee associated with valgus deformity. [22] (10.2106/jbjs.e.00827)
  • [L4] A positive malalignment sign serves as evidence for femoral derotation osteotomy. [24] (10.1007/s00167-020-06080-8)
  • [L5] A combined distal femoral osteotomy and lateral meniscus allograft transplant represents a good option for younger patients looking to avoid knee arthroplasty, provided patient selection and preoperative counseling are of the utmost importance. [26] (10.1016/j.csm.2019.02.007)
  • [L5] Osteotomy is a critical part of comprehensive treatment of young patients with knee pain, malalignment, and cartilage disorders, as it addresses both mechanical correction and the modulation of the inflammatory environment in the joint. [28] (10.1016/j.arthro.2023.08.009)
  • [L4] Internal tibial torsion seems profoundly responsive to correction of coronal plane deformity. [29] (10.5435/jaaosglobal-d-19-00009)
  • [L4] With more tibiofemoral angle correction, more congruence angle correction can be achieved, requiring simultaneous patellar stabilization. [30] (10.1186/1749-799x-4-15)
  • [L4] Forty-nine percent of patients required removal of screws from the osteotomy site. [31] (10.1177/0363546509357682)
  • [L4] Spontaneous corrective growth of the opposite epiphyseal plate can result in an inclination of the knee joint line even if the overall leg axis is restored. [32] (10.1007/s001670050022)
  • [L5] [34] (10.1016/j.jisako.2024.100347)
  • [L4] The femoral medial closing wedge osteotomy is a surgical method for improving symptoms of lateral osteoarthritis in the valgus knee. [35] (10.1007/s00167-014-2953-1)
  • [L4] [36] (10.1016/j.jisako.2024.100318)
  • [L4] The indication for concomitant tibial tubercle osteotomy should be individualized according to each patient's specific anatomical and clinical characteristics. [37] (10.1186/s13018-025-06646-7)
  • [L4] [38] (10.1016/j.eats.2025.103954)
  • [L3] MCW-DFO is an effective procedure for treating pathological valgus knees, regardless of the site of the deformity. [39] (10.1177/03635465241262437)
  • [Paper] Restoration of a neutral mechanical axis corrects maltracking and subluxation by decreasing lateral patellar forces. [40] (10.1016/j.eats.2017.08.012)
  • [L3] [41] (10.1186/s12891-026-09485-7)
  • [Paper] The improvements in the TriS-MDFO, including the diamond-shaped head, more distally oriented screws, and novel compression hook, may increase the ease and safety of medial closed wedge distal femoral osteotomy. [43] (10.1016/j.eats.2021.02.016)
  • [L3] Medial cortical hinge fractures in LOW-DFO are a common finding with three distinct fracture types. [50] (10.1007/s00167-020-06244-6)
  • [L4] [52] (10.1177/2325967116649901)
  • [L4] In patients with PFI and an associated increased FA, D-DFO achieved a significant reduction in pain, an improvement of subjective knee function, as well as an adequate correction of torsional and coronal alignment. [55] (10.1007/s00167-022-07150-9)
  • [L3] Correction of valgus knee malalignment through distal femoral varus osteotomy can reliably result in improvement in function and return to sport, provided that concomitant chondral, meniscal, and ligamentous pathology is addressed. [58] (10.1177/2325967116s00132)
  • [L3] LOW-DFO is an efficient procedure to manage lateral knee osteoarthritis in young patients with valgus deformity, with a good survival rate at 10 years and high patient satisfaction. [59] (10.1002/ksa.12404)
  • [L3] [61] (10.1002/ksa.12795)
  • [Paper] [62] (10.1016/j.eats.2015.07.012)
  • [L5] This Technical Note illustrates the preferred technique for performing a medial closing wedge distal femoral osteotomy using 3D patient-specific instrumentation in addition to a patellar osteochondral allograft transplant. [63] (10.1016/j.eats.2023.03.010)
  • [L4] Postoperative recovery is long, with a majority of patients not reaching a functional end-point by 6 or 12 months, but further improvement was found after 12 months. [69] (10.1016/j.arthro.2008.02.016)
  • [L4] [107] (10.1177/23259671251409361)
  • [L4] [110] (10.1007/s00167-013-2757-8)
  • [L1] [111] (10.1002/ksa.12021)
  • [L3] A novel classification system for patients with recurrent patellar subluxation and excessive femoral torsion based on segmental femoral torsion analysis was established. [112] (10.1186/s13018-024-05123-x)
  • [L3] In a young and active population, DFVO for valgus deformity reliably affords the ability to return to work within a relatively short time period, regardless of the occupational demand level. [116] (10.1177/2325967120965966)
  • [L4] Undergoing isolated LCW-DFO for symptomatic femoral-based varus malalignment enabled the vast majority of patients to return to sports and work along with a significant functional improvement at mid-term follow-up. [120] (10.1007/s00167-022-07303-w)
  • [L3] MPFL reconstruction combined with derotational distal femur osteotomy showed satisfactory clinical outcomes during follow-up in patients with recurrent patellar dislocation who had excessive femoral anteversion angle and trochlear dysplasia. [123] (10.1007/s00167-023-07476-y)
  • [L4] These 15-year data revealed a low rate of intraoperative complications (1.2%) and a relatively high rate of early (≤90 days) postoperative complications (42.0%) after an HTO or DFO procedure. [125] (10.1177/03635465231183092)
  • [L3] Preoperative radiographic imaging can be used to predict leg length change after valgus-correcting DFO with high reliability. [140] (10.1177/23259671251414156)
  • [L4] [142] (10.1007/s00167-020-06197-w)
  • [L4] Patients who undergo TKA after prior DFO are at increased risk of postoperative complications and revision surgery compared to primary TKA patients. [143] (10.1016/j.arth.2026.06.073)
  • [L4] [146] (10.1007/s00167-021-06466-2)
  • [L3] Tranexamic acid significantly reduces postoperative blood loss in patients undergoing distal femoral osteotomy without increasing the risk of thromboembolic complications. [147] (10.1055/s-0039-1678540)
  • [L3] Ten-year survivorship free from aseptic loosening was 95% with reliable improvement in clinical function, though there was a high complication rate secondary to problems with balancing the knee. [148] (10.1302/0301-620x.101b6.bjj-2018-1334.r2)
  • [L3] Psychological readiness to resume sporting activities correlated with knee function and was significantly higher in patients who achieved the preoperative level of sport than in patients who did not. [152] (10.1186/s12891-025-08348-x)
  • [L4] Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy. [153] (10.1007/s00167-022-06996-3)
  • [L4] Concomitant MAT and DFVO afforded a high rate of RTS at an average of 16.9 months postoperatively, as well as a significant decrease in VAS pain scores. [156] (10.1016/j.arthro.2019.07.022)
  • [L3] TKAs after VrDFO can carry an increased risk of intra-operative complications, but medium term results are comparable to arthroplasty performed as a primary intervention. [157] (10.1007/s00167-017-4487-9)
  • [L3] HTO and DFO have substantial complication rates in the short and mid term, with a higher rate of overall complications observed after DFO as compared to the HTO cohort. [159] (10.1007/s00167-022-06865-z)
  • [Case_report] The report aims to provide a lesson to surgeons regarding the unexpected complication of broken screw migration to the knee joint after hardware failure. [162] (10.1186/s12891-019-2505-4)

See Also

References

[1] Lateral Opening‐Wedge Distal Femoral Osteotomy Made Easy: Tips and Tricks. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2023.08.021

[2] Survivorship and Complications of the Distal Femoral Osteotomy. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00051

[3] Combined Correction of Coronal and Rotational Deformities of the Femur With Distal Femoral Osteotomy Using Patient-Specific Instrumentation. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251314868

[4] Sport participation after isolated distal femoral osteotomy in young patients: High return‐to‐sport rates and predictive role of preoperative activity level. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70524

[5] Distal Femoral Osteotomy: Lateral Opening Wedge Technique. Arthroscopy Techniques. 2016. DOI: 10.1016/j.eats.2016.02.037

[6] The effect of lateral opening wedge distal femoral osteotomy on leg length. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3387-5

[7] Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5 Years. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-014-4106-8

[8] Decreased femoral trochlea axial orientation corrected by derotational distal femur osteotomy in patients with patellar dislocation yields satisfactory outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12193

[9] Distal femoral osteotomy planning: Reversed Miniaci's method is more accurate than Dugdale and Paley methods. Orthopaedics & Traumatology: Surgery & Research. 2024. DOI: 10.1016/j.otsr.2023.103697

[10] Medial Closing Wedge Distal Femoral Osteotomy. Clinics in Sports Medicine. 2019. DOI: 10.1016/j.csm.2019.02.005

[11] Distal Femoral Varus Osteotomy for the Management of Valgus Deformity of the Knee. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00179

[12] Medial Closing‐Wedge Distal Femoral Osteotomy for Genu Valgum With Lateral Compartment Disease. Arthroscopy Techniques. 2016. DOI: 10.1016/j.eats.2016.08.009

[13] Good functional results of distal femoral opening-wedge osteotomy of knees with lateral osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-3988-2

[14] Distal femoral varus osteotomy outcome: Is associated femoropatellar osteoarthritis consequential?. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.04.009

[15] Posterior Plate Positioning Without Distal Placement in Medial Closing-Wedge Distal Femoral Osteotomy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261469346

[16] Single cut distal femoral osteotomy for correction of femoral torsion and valgus malformity in patellofemoral malalignment - proof of application of new trigonometrical calculations and 3D-printed cutting guides. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2140-5

[17] TT-TG distance decreases after open wedge distal femoral varization osteotomy in patients with genu valgum & patellar instability. A pilot 3D computed tomography simulation study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06832-w

[18] Osteochondral Allograft Transplantation of the Lateral Femoral Condyle and Distal Femoral Osteotomy in the Setting of Failed Osteochondritis Dissecans Fixation. Arthroscopy Techniques. 2022. DOI: 10.1016/j.eats.2022.03.014

[19] Combined Biplanar Medial Closing‐Wedge Distal Femoral Osteotomy and Quadriceps Tendon Medial Patellofemoral Ligament Reconstruction. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2021.03.013

[20] Clinical outcomes of derotational femoral osteotomy combined with medial patellofemoral ligament reconstruction in patients with patellar dislocation and increased femoral anteversion unaffected by the pattern of distribution of femoral torsion. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12015

[21] The Closing Wedge Distal Femoral Osteotomy: A Series of 19 Cases for the Management of Genu Valgum and Genu Varum. JAAOS: Global Research and Reviews. 2026. DOI: 10.5435/jaaosglobal-d-24-00139

[22] Distal Femoral Varus Osteotomy for Osteoarthritis of the Knee. Journal of Bone and Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00827

[24] Malalignment sign on knee magnetic resonance imaging: a new predictor for excessive femoral anteversion in patients with patellar dislocation. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06080-8

[26] Distal Femoral Osteotomy and Lateral Meniscus Allograft Transplant. Clinics in Sports Medicine. 2019. DOI: 10.1016/j.csm.2019.02.007

[28] Editorial Commentary: High Tibial Osteotomy and Distal Femoral Osteotomy Address Biologics and Biomechanics. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.08.009

[29] Growth Modulation for Knee Coronal Plane Deformities in Children With Nutritional Rickets: A Prospective Series With Treatment Algorithm. JAAOS: Global Research and Reviews. 2020. DOI: 10.5435/jaaosglobal-d-19-00009

[30] Varus distal femoral osteotomy in young adults with valgus knee. Journal of Orthopaedic Surgery and Research. 2009. DOI: 10.1186/1749-799x-4-15

[31] Patellofemoral Instability in Athletes. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509357682

[32] Significance of corrective growth of opposite physes in the surgical correction of deformity following epiphyseal injury around the knee joint. Knee Surgery, Sports Traumatology, Arthroscopy. 1997. DOI: 10.1007/s001670050022

[34] Patellofemoral instability part 2 (Bony procedure for patellar surgical stabilization): State of the art. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2024.100347

[35] Midterm results following medial closed wedge distal femoral osteotomy stabilized with a locking internal fixation device. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-2953-1

[36] Distal femoral osteotomies improves recurrent patellar instability in patients with genu valgum: A systematic review. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.100318

[37] A retrospective Follow-Up after derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction for the treatment of recurrent patellar dislocation. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06646-7

[38] Wedge‐less V‐Shaped Distal Femoral Osteotomy Through Lateral Approach to Correct Valgus Malalignment. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103954

[39] Outcomes of Medial Closing-Wedge Distal Femoral Osteotomy for Femoral- and Tibial-Based Valgus Deformity. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465241262437

[40] Medial Closing‐Wedge Distal Femoral Osteotomy with Medial Patellofemoral Ligament Imbrication for Genu Valgum with Lateral Patellar Instability. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2017.08.012

[41] Impact of plate placement position on the efficacy and safety of derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction in treating recurrent. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09485-7

[43] Medial Closed Wedge Distal Femoral Osteotomy Using a Novel Plate With an Optimal Compression System. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2021.02.016

[46] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 3Sports Medicine > Image KNEE INJURIES.

[50] A hinge position distal to the adductor tubercle minimizes the risk of hinge fractures in lateral open wedge distal femoral osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06244-6

[52] Opening- and Closing-Wedge Distal Femoral Osteotomy. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116649901

[55] Derotational distal femoral osteotomy for patients with recurrent patellar instability and increased femoral antetorsion improves knee function and adequately treats both torsional and valgus malalignment. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07150-9

[58] Successful Return to Sport Following Distal Femoral Varus Osteotomy. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00132

[59] Ten‐year minimal follow‐up of lateral opening wedge distal femoral osteotomy for lateral femorotibial osteoarthritis: Good survivorship and high patient satisfaction. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12404

[61] Preoperative CPAK phenotype does not affect clinical and radiological outcomes after medial closing‐wedge distal femoral osteotomy in valgus knees at 8‐year follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12795

[62] Medial Closing‐Wedge Distal Femoral Osteotomy: Fixation With Proximal Tibial Locking Plate. Arthroscopy Techniques. 2015. DOI: 10.1016/j.eats.2015.07.012

[63] Patient‐Specific Instrumentation for Medial Closing Wedge Distal Femoral Osteotomy With Patellar Osteochondral Allograft. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2023.03.010

[69] Two‐Year Results of Open‐Wedge High Tibial Osteotomy With Fixation by Medial Plate Fixator for Medial Compartment Arthritis With Varus Malalignment of the Knee. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.02.016

[70] Aaos Comprehensive Orthopaedic Review 3. Anatomy and Biomechanics of the Knee > I. Anatomy.

[71] Miller S Review Of Orthopaedics. SECTION 1 KNEE > ANATOMY (FIG. 4.1).

[73] Campbell S Operative Orthopaedics 4 Volume Set. EXTRAARTICULAR LIGAMENTOUS STRUCTURES.

[79] Campbell S Operative Orthopaedics 4 Volume Set. POSTEROMEDIAL CORNER.

[80] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Gross Anatomy.

[82] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Anterior Cruciate Ligament Anatomy.

[84] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > II. Surgical Anatomy of the Knee.

[85] Miller S Review Of Orthopaedics. ARTHRODESIS PERSON > Kinetics.

[88] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > I. Radiographic Evaluation.

[92] Aaos Comprehensive Orthopaedic Review 3. Articular Cartilage Injury and Treatment > IV. Full-­Thickness Outerbridge Grade IV Defects.

[96] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > SECTION 11 KNEE ARTHRITIS ASSESSMENT.

[97] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 3Sports Medicine > 2. Lateral Collateral Ligament Injuries.

[107] Clinical Outcomes and Accuracy of Patient-Specific Instrumentation for Corrective High Tibial and Distal Femoral Osteotomy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251409361

[110] Complication rate following high tibial open‐wedge osteotomy with spacer plates for incipient osteoarthritis of the knee with varus malalignment. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2757-8

[111] Derotational distal femoral osteotomy improves subjective function and patellar tracking after medial patellofemoral ligament reconstruction in recurrent patellar dislocation patients with increased femoral anteversion: A systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12021

[112] Derotational distal femoral osteotomy yields better outcomes in patellar subluxation with proximal femoral torsion compared with distal femoral torsion: A retrospective comparative study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05123-x

[116] Return to Work After Distal Femoral Varus Osteotomy. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120965966

[120] Favorable rates of return to activity and work following lateral closing wedge distal femoral osteotomy for femoral‐based symptomatic varus malalignment: an analysis at a mean 6‐year follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-022-07303-w

[123] Derotational distal femur osteotomy combined with medial patellofemoral ligament reconstruction yields satisfactory results in recurrent patellar dislocation with excessive femoral anteversion angle and trochlear dysplasia. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07476-y

[125] Early Postoperative Complications and Associated Variables After High Tibial Osteotomy and Distal Femoral Osteotomy: A 15-Year Experience From a Single Academic Institution. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231183092

[140] Predicting Leg Length Change After Valgus-Correcting Lateral Opening-Wedge Versus Medial Closing-Wedge Distal Femoral Osteotomy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251414156

[142] Hinge fracture in lateral closed‐wedge distal femoral osteotomy in knees undergoing double‐level osteotomy: assessment of postoperative change in rotational alignment using CT evaluation. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06197-w

[143] Complication and Reoperation Rates of Post-Distal Femoral Osteotomy Total Knee Arthroplasty versus Primary Total Knee Arthroplasty: Matched Cohorts from a Nationwide Database. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.06.073

[146] Dislocated hinge fractures are associated with malunion after lateral closing wedge distal femoral osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06466-2

[147] Tranexamic Acid Reduces Postoperative Blood Loss in Distal Femoral Osteotomy. The Journal of Knee Surgery. 2019. DOI: 10.1055/s-0039-1678540

[148] Total knee arthroplasty after distal femoral osteotomy long-term survivorship and clinical outcomes. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b6.bjj-2018-1334.r2

[152] Psychological readiness for return to sport following distal femoral osteotomy in patients with recurrent patellar instability. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08348-x

[153] Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06996-3

[156] Return to Sport and Outcomes After Concomitant Lateral Meniscal Allograft Transplant and Distal Femoral Varus Osteotomy. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2019.07.022

[157] Total knee arthroplasty after varus distal femoral osteotomy vs native knee: similar results in a case control study. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4487-9

[159] Complications after high tibial osteotomy and distal femoral osteotomy are associated with increasing medical comorbidities and tobacco use. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06865-z

[162] Case report: migration of a broken screw to the knee joint after hardware failure following closing wedge distal femoral osteotomy. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2505-4

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Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.