Distal Femoral Osteotomy: Lateral Opening

Wedge Technique
Michael P. O’Malley, M.D., Ayoosh Pareek, B.S., Patrick. J. Reardon, B.S.,
Michael J. Stuart, M.D., and Aaron J. Krych, M.D.

Abstract: Coronal limb malalignment is a significant contributor to asymmetric joint wear, gait abnormalities, and the
development and progression of degenerative joint disease. Osteotomies about the knee were developed to realign the
mechanical axis of the limb to unload the affected compartment. Valgus malalignment is less common than varus
malalignment, but can contribute to a variety of clinical conditions, including lateral compartment cartilage defects and
arthritis, lateral patellofemoral instability, and medial collateral ligament laxity. In this article, we describe our preferred
operative technique for a lateral opening wedge varus-producing distal femoral osteotomy to correct mild to moderate
valgus malalignment.

T he distal femur is the preferred site of osteotomy

for surgical correction of genu valgum deformity.1
The 2 main considerations for varus-producing
to the center of the ankle. This differs from the
anatomic axis of the lower limb, which follows a line
from the center of the femoral head, down the
femoral osteotomy are medial closing wedge and femoral shaft through the center of the tibia at the
lateral opening wedge.2 Here we will focus on lateral knee joint, to the center of the ankle, as depicted in
opening wedge osteotomy (Video 1), its stated advan- Figure 1. Abnormal lateral distal femoral angles are
tages and disadvantages, surgical indications, preoper- considered anything less than 84 degrees. Standard
ative planning, surgical technique, and clinical radiographic assessment includes a bilateral standing
outcomes (Table 1). full-length alignment view, bilateral weight-bearing
anteroposterior views in full extension, bilateral
weight-bearing posteroanterior tunnel views at 30
Surgical Technique
degrees of flexion (Rosenberg view), lateral, and
Preoperative Planning and Radiograph Templating sunrise or Merchant views. Although not routine, if
Examining both the mechanical and anatomic axes articular or meniscal pathology is suspected following
is an important consideration before surgery. The preoperative evaluation, magnetic resonance imaging
normal mechanical axis of the lower limb is defined as may be considered.
a line passing from the center of the femoral head,
through the center of the knee, and continuing down Goals
The goal of surgery is to re-create neutral alignment,
such that the mechanical axis line passes through the
From the Department of Orthopedic Surgery and Sports Medicine, Mayo center of the knee.3 The amount of correction is
Clinic, Rochester, Minnesota, U.S.A. calculated based on the angle formed between the
The authors report the following potential conflict of interest or source of mechanical axis of the femur and tibia (Fig 2). Practi-
funding: M.J.S. receives support from Arthrex and Stryker and is on the cally, 5 degrees of malalignment is the threshold to
editorial or governing board for the American Journal of Sports Medicine.
A.J.K. receives support from Arthrex, Arthritis Foundation, and Histogenics.
consider osteotomy. The calculated angle of correction
Received November 10, 2015; accepted February 11, 2016. in degrees determines the amount of wedge opening.
Address correspondence to Aaron J. Krych, M.D., Associate Professor, The geometric triangle method is commonly used,
Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, 200 First measuring the distance on a size-calibrated radio-
Street SW, Rochester, MN 55905, U.S.A. E-mail: [email protected] graph.4 This is used as the initial intraoperative
Ó 2016 by the Arthroscopy Association of North America. Open access
under CC BY-NC-ND license.
measurement and confirmed intraoperatively with
2212-6287/151054 radiographic and visual inspection of long leg
http://dx.doi.org/10.1016/j.eats.2016.02.037 alignment.

Arthroscopy Techniques, Vol 5, No 4 (August), 2016: pp e725-e730 e725

e726 M. P. O’MALLEY ET AL.

Table 1. Indications and Contraindications

Indications
 Moderate corrections up to 10 degrees for opening wedge
 Larger corrections from 12 to 27 degrees for closing wedge
 Lateral compartment mild to moderate osteoarthritis
 Lateral condyle cartilage lesions (with or without cartilage
restoration)
 Lateral meniscal transplants
Absolute contraindications
 Severe medial or tricompartmental osteoarthritis
 Symptomatic medial compartment disease
 Inflammatory arthritis
 Severe osteoporosis
Relative contraindications
 Severe patellofemoral osteoarthritis
 Nicotine use
 High body mass index
 Individuals older than 55 years

Distal Femoral Lateral Opening-Wedge

Osteotomy
The authors’ preferred technique for a distal femoral
opening-wedge osteotomy is described below with an Fig 2. Calculation of the correction using the angle formed
accompanying video demonstration (Video 1). between the mechanical axis of the femur and tibia,
respectively. This figure depicts a cropped view at the knee
as a means to demonstrate how the deformity correction is
determined. Lines drawn are as follows: Line A represents
the desired mechanical axis of the limb from the center of
the femoral head, passing through the center of the knee,
which is the goal of correction in this case. Line B represents
mechanical axis of the tibia passing from the center of the
knee to the center of the tibiotalar joint at the ankle. In this
case, the angle of correction measures 6 degrees. Line C
represents the orientation at which the lateral opening
wedge osteotomy will be made. Six degrees will be used to
calculate the distance of opening required to achieve this
correction.

Patient Positioning
The patient is placed in the supine position with the
sterile field exposing the entire limb including the iliac
crest so that the axis of the limb can be assessed intra-
operatively. Patient position must facilitate adequate
intraoperative imaging studies; thus, the operative limb
may be raised on a bump or the contralateral limb may
be lowered. This position is also ideal for the surgical
exposure to the medial femur. Fluoroscopy is assessed
prior to draping to ensure that the hip, knee, and ankle
can all be adequately imaged intraoperatively to assess
overall alignment correction. The operative limb is also
Fig 1. Depiction of both the normal mechanical and anatomic raised on a foam bump to allow for adequate lateral
axis of the lower limb in a bilateral standing full-length intraoperative imaging with less manipulation of the
anteroposterior radiograph. The mechanical axis follows a unstable osteotomy prior to fixation.
line from the femoral head through the center of the talus.
The anatomic axis follows a line through the center of the Surgical Technique
femoral shaft through the center of the tibia to the center of Two surgical approach options can be considered for a
the ankle. lateral, distal femoral osteotomy. The first is a true
 DISTAL FEMORAL OSTEOTOMY e727

Fig 5. The vastus lateralis (white arrow) is carefully lifted up

from intermuscular septum (black arrow) and the distal
medial aspect of the femoral shaft is identified. Care is taken
Fig 3. The intermuscular septum (white arrow) between to coagulate arterial branches of profunda femoris (yellow
vastus lateralis (black arrow) and biceps femoris, posterior arrow). This is an essential step in the exposure as significant
aspect of vastus medialis (yellow arrow) is identified and bleeding can be encountered if not appropriately coagulated,
elevated. Meticulous dissection in the correct plane is critical which can cause significant complications to the limb, as well
here as this will determine the exposure for the duration of as affect visualization during the procedure.
the procedure.

approach is recommended. Typically, we prefer to fin-

extra-articular approach in which a 12- to 15-cm lateral ish concomitant procedures prior to the osteotomy;
incision is made over the midline lateral femur and arthroscopy may be used for diagnostic purposes as
angulated anterior 2 cm distal to lateral epicondyle. The needed before proceeding (Fig 4). In cases of concom-
iliotibial band is split and the intermuscular septum is itant procedures, for example, lateral femoral condyle
identified (Fig 3). The vastus lateralis is elevated from osteochondral allograft transplantation is completed
intermuscular septum, being careful to coagulate arte- first to avoid hyperflexing the knee that could cause
rial branches of the profunda femoris. intraoperative loss of fixation. The arthrotomy should
If a concomitant intra-articular procedure, such as a
lateral femoral condyle cartilage procedure is to be
performed, then an extended lateral peripatellar

Fig 4. Depicted is an arthroscopic view of the lateral

compartment of the knee from the anterolateral portal.
Diagnostic arthroscopy can be used to assess for associated Fig 6. Using fluoroscopic guidance, a guide pin is placed
meniscoligamentous or cartilage injuries for concomitant approximately 2 to 3 fingerbreadths proximal to the lateral
procedures with the osteotomy. The denoted structures epicondyle and aimed just proximal to the medial epicondyle.
represent the lateral femoral condyle (A), the lateral meniscus This will determine the angle of the osteotomy made first with
(B), and the lateral tibial plateau (C). the oscillating saw, and followed by osteotomes.
e728 M. P. O’MALLEY ET AL.

Table 2. Advantages and Risks

Advantages
 Familiar surgical approach
 Access to lateral knee for concomitant procedures
 Fine-tune intraoperative correction
Risks
 Hardware irritation
 Malunion/Nonunion
 Malcorrection
 Iatrogenic fracture
 Contracture
 Neurovascular injury

Fig 7. Osteotomes are used to complete the osteotomy in safe

and effective manner. It is important not to violate the medial
cortex during this step. cortex above and below the anticipated osteotomy
helps assess any potential rotation of the femur (Fig
7). To minimize the risk of iatrogenic neurovascular
injury, the knee is then flexed to decrease tension on
be made as far proximal as possible to facilitate prox- the neurovascular bundle and increase their distance
imal hardware placement and lessen tension on the from the posterior cortex. An oscillating saw blade is
medially subluxed patella during access to the intra- used to start the osteotomy, while maintaining the
articular lateral femoral condyle. The intermuscular trajectory of the guide pin. Thin osteotomes (Stryker)
septum is released and a radiolucent retractor in order are used to complete the cut within 1 cm of the
placed to protect the tibial nerve and popliteal artery medial cortex (this distance is measured on a cali-
(Fig 5). brated preoperative x-ray and the desired measure-
A metadiaphyseal guide pin (Stryker, Kalamazoo, ment marked on the osteotome). The jack opener
MI) is placed approximately 2 to 3 fingerbreadths (Stryker) is placed and opened, and the osteotomy is
proximal to the lateral epicondyle and aimed just hinged carefully at the medial cortex slowly over
proximal to the medial epicondyle to establish the time, to take advantage of the viscoelastic properties
trajectory of the osteotomy (Fig 6). A mark on the of bone. If performing a larger correction, it is helpful
to perforate the medial cortex with a drill bit to allow
a controlled opening. A locking plate is preferred in
the setting of an unstable medial cortex. Cortico-
cancellous wedges are harvested from the femoral
neck portion of an allograft femoral head (Mayo
Clinic Surgical Bone Bank) and placed into the
osteotomy site according to the preoperative plan.
These wedges stabilize the osteotomy while the final
mechanical axis views are verified with fluoroscopy
(Fig 8). The distal, lateral femoral locking plate
(Synthes Tomofix, West Chester, PA) is then

Table 3. Pearls and Pitfalls

Pearls
 In the setting of concomitant intra-articular procedure, an
extended lateral peripatellar approach is recommended
 To minimize the risk of iatrogenic neurovascular injury, the knee is
then flexed upon retractor placement and when making the
osteotomy cut with the oscillating saw
 With larger corrections, it is helpful to perforate the medial cortex
with a drill bit to allow a controlled opening.
Pitfalls
 Undercorrection by not maintaining the cortical wedge allograft at
Fig 8. Intraoperative fluoroscopic imaging is used to confirm
the native cortex during placement of the nonlocking compression
adequate correction and plate-screw construct on the lateral screw opening osteotomy.
femoral cortex. Only after the mechanical axis has been cor-  Inaccurate trajectory of metadiaphyseal guide pin
rected will the plate be placed and secured on the lateral  Hinging on medial cortex too quickly
femoral cortex.
 DISTAL FEMORAL OSTEOTOMY e729

positioned on the lateral femoral cortex. Screw The advantages of a lateral opening wedge osteotomy
sequence involves placing the distal locking screws include a familiar surgical approach, ability to fine-tune
first, then a kickstand nonlocking screw in compres- the intraoperative correction, and access to the lateral
sion mode, followed by the proximal unicortical aspect of the knee.9,10 The disadvantages include
locking screws. It is important to maintain the cortical potential hardware irritation, a high rate of plate
wedge allograft at the native cortex during placement removal, malunion, or nonunion with the possible
of the nonlocking compression screw in order to need for bone grafting, malcorrection, contracture,
avoid undercorrection of the opening osteotomy. intra-articular fracture, breach of medial cortex, and
neurovascular injury.3,11,12 See Table 2.
Postoperative Management Distal femoral osteotomies have shown good survival
In the immediate postoperative period, all patients for up to 10 years but also have some limitations and
are placed on a chemical deep vein thrombosis pro- complications. This is a technically challenging proce-
phylaxis agent, based on preoperative risk factors. dure with reported complication rates ranging between
Postprocedure, the operative extremity is kept in a 5% and 63%.1,7,13 Incomplete osteotomy or placement
sterile cotton dressing and ace wrap bandage. The leg is of the guidewire too close to the joint predisposes to
placed in a knee immobilizer and locked in full intra-articular fracture. Failure of adequate plate fixa-
extension for mobilization/ambulation for the first tion to the cortical bone can lead to screw or plate
6 weeks. Knee range-of-motion exercises are allowed failure, collapse of the osteotomy, and malunion or
after surgery. Thromboembolic prophylaxis is provided nonunion.2 The risk of osteotomy nonunion is reported
based on preoperative risk factors. The patient is at 5% of cases in the literature and delayed union
restricted to partial weight bearing for 6 weeks, fol- taking up to 6 months in some cases.13 Allowing weight
lowed by progressive weight bearing thereafter. bearing too early in the healing process may result in
Closed-chain strengthening and low-impact, aerobic implant failure as well as collapse at the osteotomy site.
exercises are permitted according to the patient’s Unintentional perforation of the posterior femoral
symptoms. Sport-specific training and progressive cortex or poor retractor placement at the time of the
impact loading activities commence when deemed osteotomy can result in injury to the neurovascular
appropriate. Full-length standing radiographs are ob- structures.14
tained to verify correction of deformity at 3 months Potential risks using this technique include malcor-
postoperatively. rection, intra-articular fracture, neurovascular injury,
malunion or nonunion, and hardware irritation. Other
Discussion general postoperative complications may include deep
There is consistency in the literature regarding pa- vein thrombosis, pulmonary embolism, infection,
tient outcomes and longevity utilizing modern osteot- arthrofibrosis, and anterior knee pain.3,11,12 See Table 3.
omy techniques and implants. Most authors agree this The lateral opening wedge distal femoral osteotomy is
procedure is indicated for the young patient with iso- a reproducible technique for limb alignment correction
lated lateral compartment arthritis and valgus defor- in patients with valgus malalignment. Backstein et al.
mity. Kosashvili demonstrated that modified Knee reported the expected survivorship of this procedure to
Society scores significantly improved in 33 DFOs with be greater than 80% after 10 years.6 More recent
minimum 10-year follow-up. One-half of these pa- studies have shown similar results. In one study, the
tients required conversion to total knee arthroplasty at 5-year survival rate was 74% in patients with osteo-
15 years following surgery.5 Backstein et al. reviewed a arthritis and 92% in those with joint preservation
series of 40 DFOs with a mean follow-up of 10 years, procedures (such as cartilage and meniscus repair).9
demonstrating a 10-year survivorship of 82%, with a Similarly, in another recent study, the survival rates
significant decline to 45% at 15 years.6 Sixty percent were 89% at 10 years and 71% at 15 years.8 In
reported good to excellent results at most recent conclusion, this procedure remains a versatile and
follow-up, with 15% reporting fair to poor; the reliable option for addressing limb malalignment in the
majority of the latter group went on to total knee young population that may want to preserve function
arthroplasty. In their systematic review in 2012, and higher activity levels over a period of 10 or more
Saithna et al. reported similar results, with a cumula- years.
tive survival ranging between 64% and 82% at
10 years, and 45% at 15 years, with conversion to References
arthroplasty serving as the end point.7 Drexler et al. 1. Brinkman JM, Freiling D, Lobenhoffer P, Staubli AE, van
showed encouraging results for DFOs in combination Heerwaarden RJ. Supracondylar femur osteotomies
with osteochondral allograft transfer. Survivorship was around the knee: Patient selection, planning, operative
reported as 89% at 10 years, 71% at 15 years, and 24% techniques, stability of fixation, and bone healing. Ortho-
at 20 years.8 pade 2014;43:S1-S10.
e730 M. P. O’MALLEY ET AL.

2. Puddu G, Cipolla M, Cerullo G, Franco V, Gianni E. the knee. Knee Surg Sports Traumatol Arthrosc 2015;23:
Osteotomies: The surgical treatment of the valgus knee. 1317-1323.
Sports Med Arthrosc 2007;15:15-22. 9. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD.
3. Paccola CAJ, Fogagnolo F. Open-wedge high tibial Lateral opening-wedge distal femoral osteotomy: Pain
osteotomy: A technical trick to avoid loss of reduction of relief, functional improvement, and survivorship at 5
the opposite cortex. Knee Surg Sports Traumatol Arthrosc years. Clin Orthop Relat Res 2015;473:2009-2015.
2005;13:19-22. 10. Hetsroni I, Lyman S, Pearle AD, Marx RG. The effect of
4. Puddu G, Cipolla M, Cerullo G, Franco V, Giannì E. lateral opening wedge distal femoral osteotomy on medial
Which osteotomy for a valgus knee? Int Orthop 2010;34: knee opening: Clinical and biomechanical factors. Knee
239-247. Surg Sports Traumatol Arthrosc 2014;22:1659-1665.
5. Kosashvili Y, Safir O, Gross A, Morag G, Lakstein D, 11. Hooper G, Leslie H, Burn J, Schouten R, Beci I. Oblique
Backstein D. Distal femoral varus osteotomy for lateral upper tibial opening wedge osteotomy for genu varum.
osteoarthritis of the knee: A minimum ten-year follow- Oper Orthop Traumatol 2005;17:662-673.
up. Int Orthop 2010;34:249-254. 12. Dehoux E, Madi K, Fourati E, Mensa C, Segal P. High
6. Backstein D, Morag G, Hanna S, Safir O, Gross A. Long- tibial open-wedge osteotomy using a tricalcium phos-
term follow-up of distal femoral varus osteotomy of the phate substitute: 70 cases with 18 months mean follow-
knee. J Arthroplasty 2007;22:2-6. up. Rev Chir Orthop Reparatrice Appar Mot 2005;91:143-148
7. Saithna A, Kundra R, Getgood A, Spalding T. Opening [in French].
wedge distal femoral varus osteotomy for lateral 13. Edgerton BC, Mariani EM, Morrey BF. Distal femoral varus
compartment osteoarthritis in the valgus knee. Knee osteotomy for painful genu valgum. A five-to-11-year
2014;21:172-175. follow-up study. Clin Orthop Relat Res 1993;288:263-269.
8. Drexler M, Gross A, Dwyer T, et al. Distal femoral varus 14. Koyonos L, Slenker N, Cohen S. Complications in brief:
osteotomy combined with tibial plateau fresh osteo- Osteotomy for lower extremity malalignment. Clin Orthop
chondral allograft for post-traumatic osteoarthritis of Relat Res 2012;470:3630-3636.