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Fig 1

Fig. 1

A typical abnormal mistake after distal femoral osteotomy. X-rays (A) and (B) are pre-operative images. X-ray (C) indicates post-operative image with massive femoral varus(mLDFA>95°) and excessive joint line obliquity.

Fig 2

Fig. 2

Medial closing distal femoral osteotomy using an anterior biplanar cut provides higher and faster healing rate due to complete contact between the two side of the osteotomy site both in the frontal (A) and lateral plane (B). The osteotomy is performed as biplanar, leaving only the posterior 2/3 for the wedge cut and the anterior 1/3 for the ascending cut (B).

Fig 3

Fig. 3

The planning is performed according to the Miniaci method adapted for DFO, depending on the software used for digital planning. (A) indicates a pre-operative evaluation for each parameter such as mLDFA, mMPTA and WBP. (B) and (C) indicate a planning of osteotomy to have a postoperative WBP pass through the knee joint at 45% measured from the medial tibial plateau border (0 %) to the lateral tibial plateau border (100%). mLDFA: mechanical lateral distal femoral angle, mMPTA: mechanical medial proximal tibia angle, WBP: wight bearing point.

Fig 4

Fig. 4

The approach to the distal femur is oriented directly above the medial vastus. Skin incision starts from 3 cm distal point of the medial femoral epicondyle to extend about 10 cm proximally in a longitudinal way (A). The vastus medialis is lifted up by an elevator after dissection of the intermuscular septum. Then, after the periosteal tissue is released from the bony surrounding of the posterior femur, a neurovascular protection device is inserted (B).

Fig 5

Fig. 5

Under fluoroscopic AP control two K-wire are inserted in an isosceles way to form a triangle that after wedge removal leaves the femur with no cortical step off (A). The apex of the wedge is positioned directly on top of the contralateral condyle and approximately 5 mm medial from the lateral cortex (Red ring in A). A hinge protecting wire shall be inserted in between the level of joint and lateral epicondyle to ideally pass the hinge as closely lateral as possible yet maintaining in intraosseous position(B). After a careful biplane cut and removing the wedge the gap is gradually closed. When the gap could be reached to approximately 1mm of height the TM Newclip Activmotion MDF plate is positioned on the osteotomy site (C). Four distal locking screws and 3 proximal are usually enough to stabilize the osteotomy site, we rather use monocortical screws for the most proximal part of the plate (D).

Fig 6

Fig. 6

(A) indicates the image just after the plate fixation. We regularly replace the hinge protecting wire by a headless compression screw allowing easier full weight-bearing and maintaining optimal hinge safety until complete bone healing (B and C).

Fig 7

Fig. 7

The both figures before surgery(A) and after surgery(B) indicate weight bearing line(WBP) and mechanical lateral distal femoral angle(mLDFA) on whole leg standing X-ray. WBP was centralized and mLDFA was nomalized from 83.2° to 86.9°.

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Abstract

Introduction

In cases of symptomatic knee valgum, which deformity majorly originate in the femoral distal metaphysis, two main type of femoral osteotomy have been described medial closing or lateral opening. We have been doing medial closing wedges with anterior second plane cut for years. The reason being a proven similar surgical accuracy associated to a higher and faster healing rate promoted by a larger contact area between the two sides of the osteotomy site.

The Aim of the present paper is to describe up-to-date CWDFO strategies: from indication, to ideal correction, surgical technique and patient recovery.

Methods

Distal femoral varus osteotomy is indicated in painful valgus knee which deformity originated majorly in the femoral distal metaphysis.

The planning is digitally performed according to the Miniaci method using digital software to have a postoperative weight bearing line passing through the knee joint at 45-50% measured from the medial tibial plateau border (0 %) to the lateral tibial plateau border (100%).

The procedure is performed through medial closing wedges created with two medial to lateral and one posterior to anterior cutting planes creating an anterior biplanar cut.

Results

Using our step-by-step way to perform CWDFO, we standardized our radiological and clinical outcomes. Knowing some tips and tricks to avoid intra-operative complication will help readers to master this procedure.

Conclusion

Following simple intra-operative landmark and technical guidance bony deformity can be fully corrected by medial closing wedges using an anterior biplanar cut. Patients will demonstrate optimal clinical outcomes including high rate of return to recreational and professional activities.

Introduction

In case of symptomatic knee valgum, which deformity majorly originates in the distal femoral metaphysis, medial closing wedge osteotomy provide satisfactory clinical and radiological outcomes1x1Sherman, SL, Thompson, SF, and Clohisy, JCF. Distal Femoral Varus Osteotomy for the Management of Valgus Deformity of the Knee. J Am Acad Orthop Surg. May 1 2018; 26: 313–324https://doi.org/10.5435/JAAOS-D-16-00179

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.

Thisrealization implies careful planning and rigorous step by step surgical procedure2x2Eberbach, H, Mehl, J, Feucht, MJ, Bode, G, Sudkamp, NP, and Niemeyer, P. Geometry of the Valgus Knee: Contradicting the Dogma of a Femoral-Based Deformity. Am J Sports Med. Mar 2017; 45: 909–914https://doi.org/10.1177/0363546516676266

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. Following simple intra-operative landmark and technical guidance bony deformity can be fully corrected and patients will demonstrate optimal clinical outcomes including high rate of return to recreational and professional activities3x3Ciolli, G, Proietti, L, Mercurio, M et al. Return to sport following distal femur osteotomy: a systematic review. Orthop Rev (Pavia). 2022; 14: 33774https://doi.org/10.52965/001c.33774

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.

The Aim of the present paper is to describe up-to-date strategies to define indications, estimate ideal correction, plan surgical technique, perform closing wedge osteotomy and council patients in their follow-up period.

Methods

Indication of KO IN the valgus Knee

Distal femoral varus osteotomy is indicated in valgus (HKA > 183°) when the majority of the deformity stands in the distal femur (mLDFA < 85°)2x2Eberbach, H, Mehl, J, Feucht, MJ, Bode, G, Sudkamp, NP, and Niemeyer, P. Geometry of the Valgus Knee: Contradicting the Dogma of a Femoral-Based Deformity. Am J Sports Med. Mar 2017; 45: 909–914https://doi.org/10.1177/0363546516676266

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. In case of balanced femoral (mLDFA<85°) and tibial deformity (MPTA>90°) we often advocate for double level osteotomy to avoid post-operative abnormal mistakes such as massive femoral varus or excessive joint line obliquity. (fig 1)

Fig 1 Opens large image

Fig. 1

A typical abnormal mistake after distal femoral osteotomy. X-rays (A) and (B) are pre-operative images. X-ray (C) indicates post-operative image with massive femoral varus(mLDFA>95°) and excessive joint line obliquity.

At the femoral level, there are essentially two types of varus osteotomies4x4Kim, YC, Yang, JH, Kim, HJ et al. Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy. Knee Surg Relat Res. Mar 1 2018; 30: 3–16https://doi.org/10.5792/ksrr.16.064

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,5x5Chahla, J, Mitchell, JJ, Liechti, DJ et al. Opening- and Closing-Wedge Distal Femoral Osteotomy: A Systematic Review of Outcomes for Isolated Lateral Compartment Osteoarthritis. Orthop J Sports Med. Jun 2016; 4: 2325967116649901https://doi.org/10.1177/2325967116649901

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:

  • -

    Osteotomy by lateral opening

  • -

    Osteotomy by medial closing

Wylie et al., in a systematic review of the literature, there appears to be no difference between the two techniques6x6Sabbag OD, Woodmass JM, Wu IT, Krych AJ, Stuart MJ. Medial Closing-Wedge Distal Femoral Osteotomy with Medial Patellofemoral Ligament Imbrication for Genu Valgum with Lateral Patellar Instability. Arthrosc Tech. Dec 2017;6(6):e2085-e2091. doi:10.1016/j.eats.2017.08.012

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,7x7Wylie, JD, Jones, DL, Hartley, MK et al. Distal Femoral Osteotomy for the Valgus Knee: Medial Closing Wedge Versus Lateral Opening Wedge: A Systematic Review. Arthroscopy. Oct 2016; 32: 2141–2147https://doi.org/10.1016/j.arthro.2016.04.010

Abstract | Full Text | Full Text PDF | PubMed | Scopus (54)
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.We have been doing medial closing wedges for years using an anterior biplanar cut. The reason being a proven similar surgical accuracy associated to an higher and faster healing rate promoted by a larger contact area between the two sides of the osteotomy site (in the frontal and lateral plane. (fig 2)

Fig 2 Opens large image

Fig. 2

Medial closing distal femoral osteotomy using an anterior biplanar cut provides higher and faster healing rate due to complete contact between the two side of the osteotomy site both in the frontal (A) and lateral plane (B). The osteotomy is performed as biplanar, leaving only the posterior 2/3 for the wedge cut and the anterior 1/3 for the ascending cut (B).

Distal femoral Osteotomy (DFO) preoperative planning

Most of the preoperative plannings for a DFO are aimed at unloading the lateral compartment in a valgus malaligned leg with a femoral valgus deformity. In order, to reduce pain, stop or slow the degenerative process and delay joint replacement in lateral osteoarthritis these plannings aim to reposition the weight bearing line from the lateral compartment towards the medial compartment 8x8Thein, R, Bronak, S, Thein, R, and Haviv, B. Distal femoral osteotomy for valgus arthritic knees. J Orthop Sci. Nov 2012; 17: 745–749https://doi.org/10.1007/s00776-012-0273-1

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. In general, the authors plan to have a postoperative weight bearing line passing the knee joint after correction at 45-50% measured from the medial tibial plateau border (0 %) to the lateral tibial plateau border (100%) (fig 3B). The planning is performed according to the Miniaci method 9x9Miniaci, A, Ballmer, FT, Ballmer, PM, and Jakob, RP. Proximal tibial osteotomy. A new fixation device. Clin Orthop Relat Res. Sep 1989; : 250–259

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adapted for DFO. This so-called inverted Miniaci method of planning 10x10Ollivier, M, Fabre-Aubrespy, M, Micicoi, G, Ehlinger, M, Hanak, L, and Kley, K. Lateral femoral closing wedge osteotomy in genu varum. Orthop Traumatol Surg Res. Nov 2021; 107: 102989https://doi.org/10.1016/j.otsr.2021.102989

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consists of a step-by-step approach in which first the existent Mickulicz's line is drawn between the centre of the hip and the centre of the ankle joint. Then the intended correction is marked on a line between the medial and lateral border of the proximal tibia and the intended Mickulicz's line is drawn from the ankle joint centre passing the marked point at the knee up to the hip level. If the length of the two Mickulicz's lines are the same the proximal endpoint is the new hip centre. Now the hinge point for the osteotomy is marked at the distal femur, for a medial closing wedge correction near the lateral border just above the lateral femoral condyle, and for a lateral opening wedge correction near the medial cortex just proximal of the medial femoral condyle. Then lines are drawn from the hinge point to the old and the new hip centres and the angle between these lines is measured. This angle, the angle of correction, is then projected on the distal femur starting at the hinge point and ending in the area of the medial metaphysial flare for a biplanar medial closing wedge correction or the lateral metaphysial flare for a biplanar lateral opening wedge correction. In a calibrated radiograph the distance measured between the lines of the wedge ending at or passing the medial or lateral cortex, respectively, resembles the height of the wedge to be resected in a closing wedge correction or the height of the wedge to be created in an opening wedge correction. In an opening wedge correction, the sawblade used results in bone loss at the cortex so to ensure an accurate correction the sawblade thickness should be added to the measured opening distance.

Fig 3 Opens large image

Fig. 3

The planning is performed according to the Miniaci method adapted for DFO, depending on the software used for digital planning. (A) indicates a pre-operative evaluation for each parameter such as mLDFA, mMPTA and WBP. (B) and (C) indicate a planning of osteotomy to have a postoperative WBP pass through the knee joint at 45% measured from the medial tibial plateau border (0 %) to the lateral tibial plateau border (100%). mLDFA: mechanical lateral distal femoral angle, mMPTA: mechanical medial proximal tibia angle, WBP: wight bearing point.

Depending on the software used for digital planning, the planning steps described above may have a different order, however, the result will be the same (fig 3).

Our Surgical Technique. (Video 1)

The patient is positioned in supine position. The foot of the operated limb has to overhang the distal border of the split leg table by approximately 5 cm.

The contralateral leg must be lowered by 5° to gain proper access to the medial surrounding of the distal thigh. A bolster in the back of the thigh may prevent the femur to fall back after completion of the osteotomy, preventing hinge-breakage due to the limbs weight.

Routine scrubbing and draping, double drapes are highly recommended.

The approach to the distal femur is oriented directly above the medial vastus.

Starting some 3 cm distal to the medial femoral epicondyle it extends approximately 5 cm proximally (fig 4A). After sharp skin incision and blunt dissection, the muscular fascia of the vastus medialis is reached.

Fig 4 Opens large image

Fig. 4

The approach to the distal femur is oriented directly above the medial vastus. Skin incision starts from 3 cm distal point of the medial femoral epicondyle to extend about 10 cm proximally in a longitudinal way (A). The vastus medialis is lifted up by an elevator after dissection of the intermuscular septum. Then, after the periosteal tissue is released from the bony surrounding of the posterior femur, a neurovascular protection device is inserted (B).

This should be incised in a longitudinal way and the vastus medialis, along with the vastus medialis obliquus fibers has to be lifted out of its bed from the intermuscular septum to the ventral side. Once these fibers have been elevated the surgeon gains full access to the medial surrounding of the distal femur from the medial aspect.

After preparation of the intermuscular septum in many cases we see three tiny vessels in AP orientation. These so-called “three sisters” indicate roughly the level of osteotomy. At this level the intramuscular muscular septum has to be incised.

Because of the perfusion and to prevent bleeding it is good practice to perform this step with an electrocautery device. Any bleeding has to be cauterized or ligated. After the dissection of the intermuscular septum immediate access to the posterior surrounding of the femur is granted. To free the posterior femur from any soft tissue adherence a semi-blunt periosteal elevator is inserted, and the periosteal tissue released from the bony surrounding of the posterior femur, until the contralateral condyle is reached.

After this procedure digital palpation of the whole posterior aspect of the femur shall be possible and a neurovascular protection device can be inserted in the forecasted orientation of the osteotomy(fig 4B).  Then under fluoroscopic AP control the osteotomy is marked. For that purpose, in a closing wedge scenario two K-wire are inserted in an isosceles way to form a triangle that after wedge removal leaves the femur with no cortical step off.

The apex of the wedge to be removed is positioned directly on top of the contralateral condyle and approximately 5 mm medial of the lateral cortex (fig 5A). This hinge position is the area of rotation. For practical reasons it makes good sense to place these k-wires rather in the posterior aspect of the distal femur as the osteotomy is performed as biplanar, leaving only the posterior 2/3 for the wedge cut. The anterior 1/3 of the osteotomy is the ascending biplanar osteotomy cut (fig 2). After determining and marking this anterior biplane cut with the electrocautery and confirmation of the correct positioning of the wedge defying k-wires and proper posterior neurovascar protection the wedge is cut out within the boundaries of the defying K wires. The resulting wedge can be removed. For these cuts a narrow saw blade of approximately 2 cm width and sufficient length has to be taken. As by this moment the osteotomies still remain stable due to the incomplete cut off only the posterior 2/3 of the distal femur now a hinge protecting wire shall be inserted (fig 5B). A good estimation is to enter the skin in between the level of joint and lateral epicondyle. From there on the k-wire is deviated proximally approximating the flare of the lateral condyle to ideally pass the hinge as closely lateral as possible yet maintaining in intraosseous position.

Fig 5 Opens large image

Fig. 5

Under fluoroscopic AP control two K-wire are inserted in an isosceles way to form a triangle that after wedge removal leaves the femur with no cortical step off (A). The apex of the wedge is positioned directly on top of the contralateral condyle and approximately 5 mm medial from the lateral cortex (Red ring in A). A hinge protecting wire shall be inserted in between the level of joint and lateral epicondyle to ideally pass the hinge as closely lateral as possible yet maintaining in intraosseous position(B). After a careful biplane cut and removing the wedge the gap is gradually closed. When the gap could be reached to approximately 1mm of height the TM Newclip Activmotion MDF plate is positioned on the osteotomy site (C). Four distal locking screws and 3 proximal are usually enough to stabilize the osteotomy site, we rather use monocortical screws for the most proximal part of the plate (D).

After hinge wire positioning the ascending biplane cut is performed. To avoid a “drive-through scenario” leaving the biplane cut proximately intact it is recommended to first cut the medial aspect in proximal direction until the femur at the highest anterior surrounding is exited with the sawblade. From there on the lateral aspect of the biplane osteotomy is cut by deviating the saw blade distally.

Off to completion of this interior cups the osteotomy immediately becomes unstable. By gentle manipulation the capability to close the gap can be assessed. One must not force the osteotomy to close by manipulation at the foot. Also rotation in this phase has to be avoided.

In case the osteotomy gap does not close by gentle pressure, the distal K-wire shall be removed. Then, by repetitive insertion of the sawblade, starting off from the hinge-point under constant cutting, the maintaining remnants can be removed.

Gradually, the osteotomy gap should close. Sometimes the tip-pressure of the sawblade forcing the knee to go laterally is enough, to close the gap fully. When the gap is closed to approximately 1 mm of height the sawblade is captured within the osteotomy wedge. When that is reached, a sufficient approximation is accomplished to compress the osteotomy via the oblong hole within the TM Newclip Activmotion MDF plate (fig 5C).

Four distal locking screws and 3 proximal are usually enough to stabilize the osteotomy site, we rather use monocortical screws for the most proximal part of the plate to spare two intact cortical fixations in our rare cases of revision (fig 5D).

Once the plate is fixed, the hinge protective k-wire is removed, we regularly replace it by a headless compression screw allowing easier full weight-bearing and maintaining optimal hinge safety until complete bone healing (fig 6).

Fig 6 Opens large image

Fig. 6

(A) indicates the image just after the plate fixation. We regularly replace the hinge protecting wire by a headless compression screw allowing easier full weight-bearing and maintaining optimal hinge safety until complete bone healing (B and C).

The closure of the wound is made in a three-layer fashion (inter-muscular septum, subcutaneous tissue, and skin).

Patient rehabilitation

Patients are usually to perform partial weight bearing the day of the surgery without using a brace and a restriction of range of motion, then return to full weight bearing is allowed based on patient's tolerance11x11Dawson, MJ, Ollivier, M, Menetrey, J, and Beaufils, P. Osteotomy around the painful degenerative varus knee: a 2022 ESSKA formal consensus. Knee Surg Sports Traumatol Arthrosc. Jun 13 2022; https://doi.org/10.1007/s00167-022-07024-0

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. Our procedures such as an anterior biplanar cut and a hinge protective headless compression screw allow easier full weight-bearing.

We advise knee osteotomy surgeon to follow patients at 1 month, 3, 6, 12 months then every year to be able to identify early complications and failures.

Figure 7 and Table 1.

Fig 7 Opens large image

Fig. 7

The both figures before surgery(A) and after surgery(B) indicate weight bearing line(WBP) and mechanical lateral distal femoral angle(mLDFA) on whole leg standing X-ray. WBP was centralized and mLDFA was nomalized from 83.2° to 86.9°.

Table 1Presents our tips and tricks. For CWDFO.Table 1. Our tips and tricks
INDICATION.PLANNING.SURGERY.
  • The is only one “pure” indication of medial closing wedge DFO: painful valgus knee which Deformity originates majorly in the distal femoral metaphysis.

  • Planning is done on perfectly oriented legs on a long axis xray.

  • Support the femur in supine position

  • And Lower the contralateral limb in mcwDFO

  • No pressure and no rush during osteotomy site closure

  • All other indication should be considered as border line and will probably present with unpredictible outcomes.

  • Normal mLDFA is 87+/3

  • Normal MPTA is 87+/-3

  • Normal JLCA is 0+/-2

  • Beware adductor canal during dissection, neurovascular structure are always closer than you think.

  • Perform a lateral x-ray before drilling

  • Reversed miniaci planning is the most accurate way to plan cutting plane, hinge position and adapted wedge height

  • One k-wire per osteotomy is sufficient to drive the saw (one for each cut)

  • Secure the hinge if needed (hinge screw)

  • Isolated mCWDFO is potentially indicated when mLDFA<85 AND MPTA<90

  • Use a hinge-wire to protect the hinge.

  • Ideal correction should tend to neutral postoperative alignment.

  • Always perfom biplanar cuts (oblique, 4cm long… don't be to horizontal !)

  • Optimal cutting plane end at the lateral hinge position: 5mm to the Lateral cortex and. as close as possible to lateral epidcondyle.

  • Fully perform your cuts (check posterior cortex and biplanar cuts with a thin metal ruler)

View Table in HTML

Patient usually return to work between 2 to 3 Months and to non impact sport (cycling, swimming, gym…) at 4 Months11x11Dawson, MJ, Ollivier, M, Menetrey, J, and Beaufils, P. Osteotomy around the painful degenerative varus knee: a 2022 ESSKA formal consensus. Knee Surg Sports Traumatol Arthrosc. Jun 13 2022; https://doi.org/10.1007/s00167-022-07024-0

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.

Pivot sport and high sports should be contra-indicated until complete bone healing (4-6 months) confirmed on lateral and AP radiographs11x11Dawson, MJ, Ollivier, M, Menetrey, J, and Beaufils, P. Osteotomy around the painful degenerative varus knee: a 2022 ESSKA formal consensus. Knee Surg Sports Traumatol Arthrosc. Jun 13 2022; https://doi.org/10.1007/s00167-022-07024-0

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.

DISCUSSION

Medial CWDFO and Lateral OWDFO are two main surgical options for lateral compartment arthritis with valgus knee deformity12x12Diaz, CC, Lavoie-Gagne, OZ, Knapik, DM, Korrapati, A, Chahla, J, and Forsythe, B. Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques. Am J Sports Med. Feb 14 2022; : 3635465211051740https://doi.org/10.1177/03635465211051740

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. There is a certain difference between these techniques in the literature, although systematic reviews showed that the clinical outcomes including the survival rate and patient-reported outcomes did not significantly differ between Medial CWDFO and Lateral OWDFO 7x7Wylie, JD, Jones, DL, Hartley, MK et al. Distal Femoral Osteotomy for the Valgus Knee: Medial Closing Wedge Versus Lateral Opening Wedge: A Systematic Review. Arthroscopy. Oct 2016; 32: 2141–2147https://doi.org/10.1016/j.arthro.2016.04.010

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,12x12Diaz, CC, Lavoie-Gagne, OZ, Knapik, DM, Korrapati, A, Chahla, J, and Forsythe, B. Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques. Am J Sports Med. Feb 14 2022; : 3635465211051740https://doi.org/10.1177/03635465211051740

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. Lateral OWDFO is known to be technically easier and precise4x4Kim, YC, Yang, JH, Kim, HJ et al. Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy. Knee Surg Relat Res. Mar 1 2018; 30: 3–16https://doi.org/10.5792/ksrr.16.064

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. It allows intraoperative alignment adjustments with opening devices5x5Chahla, J, Mitchell, JJ, Liechti, DJ et al. Opening- and Closing-Wedge Distal Femoral Osteotomy: A Systematic Review of Outcomes for Isolated Lateral Compartment Osteoarthritis. Orthop J Sports Med. Jun 2016; 4: 2325967116649901https://doi.org/10.1177/2325967116649901

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. Height restoration and less exposure to critical neurovascular structures are also advantages of the procedure4x4Kim, YC, Yang, JH, Kim, HJ et al. Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy. Knee Surg Relat Res. Mar 1 2018; 30: 3–16https://doi.org/10.5792/ksrr.16.064

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. However, Lateral OWDFO carries a higher risk of hinge fracture through medial cortex and of bone healing complications such as nonunion, malunion and delayed union4x4Kim, YC, Yang, JH, Kim, HJ et al. Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy. Knee Surg Relat Res. Mar 1 2018; 30: 3–16https://doi.org/10.5792/ksrr.16.064

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. The procedure results in less stability 13x13Brinkman, JM, Hurschler, C, Agneskirchner, JD, Freiling, D, and van Heerwaarden, RJ. Axial and torsional stability of supracondylar femur osteotomies: biomechanical comparison of the stability of five different plate and osteotomy configurations. Knee Surg Sports Traumatol Arthrosc. Apr 2011; 19: 579–587https://doi.org/10.1007/s00167-010-1281-3

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and needs the opening gap to be filled with either autologous, allogenous or artificial bone grafting12x12Diaz, CC, Lavoie-Gagne, OZ, Knapik, DM, Korrapati, A, Chahla, J, and Forsythe, B. Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques. Am J Sports Med. Feb 14 2022; : 3635465211051740https://doi.org/10.1177/03635465211051740

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. In the Medial CWDFO, the advantages are faster healing time and lower risk of hinge fracture as a result of direct bony opposition along with the cortex, while the procedure is more technically demanding and is needed to be very reliant on the preoperative plan for accuracy of bony resection6x6Sabbag OD, Woodmass JM, Wu IT, Krych AJ, Stuart MJ. Medial Closing-Wedge Distal Femoral Osteotomy with Medial Patellofemoral Ligament Imbrication for Genu Valgum with Lateral Patellar Instability. Arthrosc Tech. Dec 2017;6(6):e2085-e2091. doi:10.1016/j.eats.2017.08.012

Google ScholarSee all References
,8x8Thein, R, Bronak, S, Thein, R, and Haviv, B. Distal femoral osteotomy for valgus arthritic knees. J Orthop Sci. Nov 2012; 17: 745–749https://doi.org/10.1007/s00776-012-0273-1

Abstract | Full Text PDF | PubMed | Scopus (41)
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. In general, postoperative rehabilitation is faster and weight bearing is earlier by 2–4 weeks than Lateral OWDFO4x4Kim, YC, Yang, JH, Kim, HJ et al. Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy. Knee Surg Relat Res. Mar 1 2018; 30: 3–16https://doi.org/10.5792/ksrr.16.064

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Biplanar strategies in DFO generally result in stronger rotational stability and better bone healing by an increase of the contact area inside of the osteotomy site13x13Brinkman, JM, Hurschler, C, Agneskirchner, JD, Freiling, D, and van Heerwaarden, RJ. Axial and torsional stability of supracondylar femur osteotomies: biomechanical comparison of the stability of five different plate and osteotomy configurations. Knee Surg Sports Traumatol Arthrosc. Apr 2011; 19: 579–587https://doi.org/10.1007/s00167-010-1281-3

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,14x14Pietsch, M, Hochegger, M, Winkler, M, Sandriesser, S, Freude, T, and Augat, P. Opening-wedge osteotomies of the distal femur: minor advantages for a biplanar compared to a uniplanar technique. Knee Surg Sports Traumatol Arthrosc. Jul 2019; 27: 2375–2384https://doi.org/10.1007/s00167-018-5332-5

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. Those procedures reduce the external rotation and tended to increase the torsional stiffness. Furthermore, horizontal cuts of biplanar distal femoral osteotomy are positioned closer to the joint where metaphysal blood supply enhance bone ability to heal13x13Brinkman, JM, Hurschler, C, Agneskirchner, JD, Freiling, D, and van Heerwaarden, RJ. Axial and torsional stability of supracondylar femur osteotomies: biomechanical comparison of the stability of five different plate and osteotomy configurations. Knee Surg Sports Traumatol Arthrosc. Apr 2011; 19: 579–587https://doi.org/10.1007/s00167-010-1281-3

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| Google ScholarSee all References
. In monoplanar fashioned osteotomies, anterior cortex completed cuts would breach femoro-patellar and often need more proximal (diaphysal) osteotomy site15x15van Heerwaarden, R, Najfeld, M, Brinkman, M, Seil, R, Madry, H, and Pape, D. Wedge volume and osteotomy surface depend on surgical technique for distal femoral osteotomy. Knee Surg Sports Traumatol Arthrosc. Jan 2013; 21: 206–212https://doi.org/10.1007/s00167-012-2127-y

Crossref | PubMed | Scopus (38)
| Google ScholarSee all References
16x16van der Woude, JA, Spruijt, S, van Ginneken, BT, and van Heerwaarden, RJ. Distal femoral valgus osteotomy: bone healing time in single plane and biplanar technique. Strategies Trauma Limb Reconstr. Nov 2016; 11: 177–186https://doi.org/10.1007/s11751-016-0266-2

Crossref | PubMed | Scopus (21)
| Google ScholarSee all References
.

New technologies such as 3D patient-specific cutting guide, computer-assisted procedure and navigation assistance for knee around osteotomy were recently reported17x17Saragaglia, D, Chedal-Bornu, B, Rouchy, RC, Rubens-Duval, B, Mader, R, and Pailhe, R. Role of computer-assisted surgery in osteotomies around the knee. Knee Surg Sports Traumatol Arthrosc. Nov 2016; 24: 3387–3395https://doi.org/10.1007/s00167-016-4302-z

Crossref | PubMed | Scopus (27)
| Google ScholarSee all References
, 18x18Arnal-Burró, J, Pérez-Mañanes, R, Gallo-del-Valle, E, Igualada-Blazquez, C, Cuervas-Mons, M, and Vaquero-Martín, J. Three dimensional-printed patient-specific cutting guides for femoral varization osteotomy: Do it yourself. The Knee. 2017; 24: 1359–1368https://doi.org/10.1016/j.knee.2017.04.016

Abstract | Full Text | Full Text PDF | PubMed | Scopus (38)
| Google ScholarSee all References
, 19x19Ribeiro, CH, Severino, NR, and Fucs, PM. Preoperative surgical planning versus navigation system in valgus tibial osteotomy: a cross-sectional study. Int Orthop. Aug 2013; 37: 1483–1486https://doi.org/10.1007/s00264-013-1960-z

Crossref | PubMed | Scopus (22)
| Google ScholarSee all References
, 20x20Donnez, M, Ollivier, M, Munier, M et al. Are three-dimensional patient-specific cutting guides for open wedge high tibial osteotomy accurate? An in vitro study. J Orthop Surg Res. Jul 9 2018; 13: 171https://doi.org/10.1186/s13018-018-0872-4

Crossref | PubMed | Scopus (42)
| Google ScholarSee all References
. Clinical Studies showed that these new techniques were reliable, reproducible and accurate21x21Saragaglia, D and Chedal-Bornu, B. Computer-assisted osteotomy for valgus knees: Medium-term results of 29 cases. Orthopaedics & Traumatology: Surgery & Research. 2014; 100: 527–530https://doi.org/10.1016/j.otsr.2014.04.002

Abstract | Full Text | Full Text PDF | PubMed | Scopus (28)
| Google ScholarSee all References
, 22x22Grasso, F, Martz, P, Micicoi, G et al. Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients. Int Orthop. Mar 2022; 46: 473–479https://doi.org/10.1007/s00264-021-05194-z

Crossref | PubMed | Scopus (8)
| Google ScholarSee all References
, 23x23Chaouche, S, Jacquet, C, Fabre-Aubrespy, M et al. Patient-specific cutting guides for open-wedge high tibial osteotomy: safety and accuracy analysis of a hundred patients continuous cohort. Int Orthop. Dec 2019; 43: 2757–2765https://doi.org/10.1007/s00264-019-04372-4

Crossref | PubMed | Scopus (43)
| Google ScholarSee all References
. In Lateral OWDFO, C. Jacquet et al reported that the use of patient-specific cutting guide improved the accuracy of correction in both the coronal and sagittal planes compared to conventional technique24x24Jacquet, C, Chan-Yu-Kin, J, Sharma, A, Argenson, JN, Parratte, S, and Ollivier, M. More accurate correction using "patient-specific" cutting guides in opening wedge distal femur varization osteotomies. Int Orthop. Oct 2019; 43: 2285–2291https://doi.org/10.1007/s00264-018-4207-1

Crossref | PubMed | Scopus (26)
| Google ScholarSee all References
. But the very few studied reported about new technologies of Medial CWDFO, although Shi J et al reported that 3D patient-specific printed cutting guides for Medial CWDFO increased the precision and offer less fluoroscopic and surgical time25x25Shi, J, Lv, W, Wang, Y et al. Three dimensional patient-specific printed cutting guides for closing-wedge distal femoral osteotomy. Int Orthop. Mar 2019; 43: 619–624https://doi.org/10.1007/s00264-018-4043-3

Crossref | PubMed | Scopus (33)
| Google ScholarSee all References
. Conventional technique with free handed technique which is a majority of Medial CWDFO offered the acceptable clinical outcomes4x4Kim, YC, Yang, JH, Kim, HJ et al. Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy. Knee Surg Relat Res. Mar 1 2018; 30: 3–16https://doi.org/10.5792/ksrr.16.064

Crossref | PubMed | Scopus (26)
| Google ScholarSee all References
,5x5Chahla, J, Mitchell, JJ, Liechti, DJ et al. Opening- and Closing-Wedge Distal Femoral Osteotomy: A Systematic Review of Outcomes for Isolated Lateral Compartment Osteoarthritis. Orthop J Sports Med. Jun 2016; 4: 2325967116649901https://doi.org/10.1177/2325967116649901

Crossref | Scopus (58)
| Google ScholarSee all References
,7x7Wylie, JD, Jones, DL, Hartley, MK et al. Distal Femoral Osteotomy for the Valgus Knee: Medial Closing Wedge Versus Lateral Opening Wedge: A Systematic Review. Arthroscopy. Oct 2016; 32: 2141–2147https://doi.org/10.1016/j.arthro.2016.04.010

Abstract | Full Text | Full Text PDF | PubMed | Scopus (54)
| Google ScholarSee all References
,10x10Ollivier, M, Fabre-Aubrespy, M, Micicoi, G, Ehlinger, M, Hanak, L, and Kley, K. Lateral femoral closing wedge osteotomy in genu varum. Orthop Traumatol Surg Res. Nov 2021; 107: 102989https://doi.org/10.1016/j.otsr.2021.102989

Abstract | Full Text | Full Text PDF | Scopus (8)
| Google ScholarSee all References
,12x12Diaz, CC, Lavoie-Gagne, OZ, Knapik, DM, Korrapati, A, Chahla, J, and Forsythe, B. Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques. Am J Sports Med. Feb 14 2022; : 3635465211051740https://doi.org/10.1177/03635465211051740

Crossref | Scopus (2)
| Google ScholarSee all References
. In Medial CWDFO, further studies are needed to analyze the role of new technologies in our quest for accuracy and precision.

Conclusion

Following simple intra-operative landmark and technical guidance bony deformity can be fully corrected by medial closing wedges using an anterior biplanar cut and patients will demonstrate optimal clinical outcomes including high rate of return to recreational and professional activities.

Declarations

Conflict of interest

MO, KK are educational consultant for newclips technique

LRF is Chief medical officer for Peek-Med

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical approval

No Ethical approval was required for the present study

Informed consent

Informed consent was obtained from all individual participants included in the study.

Authors’ contribution

JA and CJ wrote the initial manuscript.

MO performed surgery, voice-overed video, corrected the final manuscript.

KK and LR corrected the Final manuscript.

VIDEO Description

This video presents the case of right varus closing wedge osteotomy in the knee valgus.

Planning

The automatic software asks the calibration and positioning landmarks such as femoral head, great trochanter, distal aspect of medial and lateral condyle, proximal aspect of medial and lateral tibia plateau, and both edge of proximal tibia plateau and talus. After that, all premeasured angle such as mechanical Lateral Distal Femoral Angle(mLDFA), mechanical Medial Proximal Tibia Angle (MPTA), Joint Line Conversion Angle (JLCA) and Weight Bearing line Position(WBlP) will be provided automatically and we can recognize if the bone deformity would owe femoral or tibia side.

Then, we decide the hinge position, the entry point of distal closing osteotomy and WBlP at the end of surgery(45 to 50%). The software performs the correction of osteotomy to obtain neutral WBlP, provides the resection wedges and mLDFA value at the end of surgery.

Procedure

A 6cm skin incision surrounding the medial epicondyle is performed. We open intermuscular fascia and dissect vastus medialis to be lifted up by anterior retractor. Posterior retractor is positioned just behind posterior cortex to protect neurovascular structures. The first k-wire is inserted from the lateral cortex to the hinge point under fluoroscopic control. The second k-wire does not cross the first one before the hinge point and is inserted as making an isosceles triangle (two k-wires and lateral cortex). The hinge k-wire is inserted from distal to proximal to avoid hinge's fractures. During. the sawing process, an anterior biplanar cut is performed located at 1/3 anterior part of femoral bone and providing additiona rotational stability tot he osteotomy site.

The horizontal biplanar cut is performed along with 2 k-wires at the 2/3 posterior part for two of femoral bone. After removal of 2 k-wires the osteotomy gap should close by itself. The Newclip Activmotion MDF plate is positioned properly to fix distal locking screws. Finally proximal screws are fixed after compressing the osteotomy gap by using one or two cortical screws.

Declaration of Competing Interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.+

Appendix. Supplementary materials

REFERENCES

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  22. 22Grasso, F, Martz, P, Micicoi, G et al. Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients. Int Orthop. Mar 2022; 46: 473–479https://doi.org/10.1007/s00264-021-05194-z
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  24. 24Jacquet, C, Chan-Yu-Kin, J, Sharma, A, Argenson, JN, Parratte, S, and Ollivier, M. More accurate correction using "patient-specific" cutting guides in opening wedge distal femur varization osteotomies. Int Orthop. Oct 2019; 43: 2285–2291https://doi.org/10.1007/s00264-018-4207-1
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