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Distal Femoral Varus Osteotomy for Osteoarthritis of the Knee
Jun-Wen Wang, MD1; Chia-Chen Hsu, MD1
1 Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Kaohsiung, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan, Republic of China. E-mail address for J.-W. Wang: lee415@adm.cgmh.org.tw
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Jan 01;87(1):127-133. doi: 10.2106/JBJS.C.01559
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Abstract

Background: Distal femoral varus osteotomy is a procedure that is performed for the treatment of lateral-compartment osteoarthritis of the knee as well as for correction of the associated valgus deformity. However, its role remains controversial and its efficacy in the treatment of associated patellofemoral arthritis has not been well studied. The purpose of the present study was to evaluate the outcome after distal femoral osteotomy performed for the treatment of painful genu valgum and to assess the influence of patellofemoral arthritis on the results.

Methods: Thirty patients (thirty knees) were managed with distal femoral varus osteotomy for the treatment of noninflammatory lateral-compartment arthritis of the knee associated with a valgus deformity. Twelve knees had isolated lateral-compartment arthritis, ten had mild-to-moderate degenerative changes in the other two compartments, and eight knees had severe patellofemoral arthritis in addition to lateral-compartment disease. The osteotomy site was fixed with a 90° blade-plate. After a mean duration of follow-up of ninety-nine months, all patients were evaluated with use of the Hospital for Special Surgery knee-rating system and a physical examination.

Results: At the time of the most recent follow-up, twenty-five patients (83%) had a satisfactory result and two had a fair result according to the Hospital for Special Surgery rating system. The remaining three patients had had a conversion to a total knee arthroplasty. With conversion to total knee arthroplasty as the end point, the cumulative ten-year survival rate for all patients was 87% (95% confidence interval, 69% to 100%). Improvement in patellar tracking, which persisted at the time of the latest follow-up, was observed in seven of the eight knees with associated severe patellofemoral arthritis.

Conclusions: 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. The result of the osteotomy does not appear to be affected by the presence of severe patellofemoral arthritis.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Jun-Wen Wang
    Posted on January 28, 2005
    Drs. Wang and Hsu respond to Dr. Grelsamer
    Chang Gung Memorial Hospital, Taiwan, Republic of China

    To the Editor:

    Dr. Grelsamer has mentioned a very good point on choosing the site of osteotomy when correction of the valgus deformity of the knee is indicated. Traditionally, a corrective osteotomy is performed at the site of deformity to create a horizontal joint line. However, if the valgus deformity of the knee exceeds 12 degrees and there is depression of the lateral tibial plateau as depicted in Figure 2 of our article, the issue concerning the proper site of corrective osteotomy is raised.

    In our series, two of 30 knees with valgus deformity resulted from old fracture of the lateral tibial condyle. The tibiofemoral angles of both knees were 15 degrees of valgus before osteotomy. At that time, we followed the principles of Coventry[1],-- if the valgus angulation of the knee exceeds 12 degrees, the osteotomy should be done at the supracondylar area of the femur. Both knees had adequate correction of the deformity to 0 degrees of tibiofemoral angulation immediately after osteotomy. At the recent follow-up (8 years postoperatively) of both knees, the tibiofemoral angulation was 1 degree and 2 degrees of varus respectively and both patients were satisfied with the result.

    We think Dr. Grelsamer has raised a very good issue in this particular situation, which we believe, has not been mentioned before. We consider if adequate correction is performed either by distal femoral or proximal tibial varus osteotomy, a satisfactory clinical result will be anticipated. As to the technique of the osteotomy, we prefer distal femoral varus osteotomy partly because we are familiar with this technique, and partly because we are concerned possible injury to the peroneal nerve if 15 degrees or more of varus correction is to be done. Importantly, if the deformity is not overcorrected is not for fear of nerve injury, the deformity may recur[2].

    --- Jun-Wen Wang, MD Chin-Chen Hsu, MD Corresponding author: Jun-Wen Wang, MD Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Kaohsiung

    No. 123 Ta Pei Rd., Niao Sung Hsiang, Kaohsiung Hsien, Taiwan, Republic of China

    References:

    1. Coventry MB. Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee. J Bone Joint Surg AM 1987;69:32-8.

    2. Maquet PGJ. Biomechanics of the knee: with application to the pathogenesis and the surgical treatment of osteoarthritis. 2nd ed. New York: Springer; 1984. p.276.

    Ronald P. Grelsamer
    Posted on January 24, 2005
    Dangerous indications for femoral osteotomies?
    Hospital for Joint Diseases

    To the Editor:

    The authors should be congratulated on a series of technically well- executed osteotomies. However, because orthopaedists in training use this Journal as a foundation for their education I am concerned about the message that this paper delivers.

    Specifically, the authors appear to have violated the traditional principle that an osteotomy about the knee should be carried out on the side of the deformity. The penalty for this violation is usually an oblique joint line, persistent pain, and a challenging knee replacement.

    Figure 2 a-c shows a patient whose valgus is secondary to an impressive deficit of the lateral plateau. The distal femur is normal. Yet, the authors have performed a femoral osteotomy that has predictably led to an oblique joint line. At eight years, the authors report that the patient is doing well. We do not know if or when the patient will need a joint replacement or how challenging that arthoplasty will be. Would a relatively easy primary knee replacement not have been preferable as the index procedure?

    Should we no longer be teaching that an osteotomy is preferably performed on the side of the joint where the deformity lies?

    Either way, these principles should have warranted a serious discussion at some point in the paper. Perhaps it is not too late.

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