Medial Closing-Wedge Distal Femoral Osteotomy

What is the problem?

Like all joints, the knee is covered with cartilage, a slippery substance with no nerve endings that allows the joint to move freely and painlessly. This cartilage can wear for various reasons (excess weight, sequelae of a meniscectomy or a fracture…) exposing the underlying bone, which is rough and innervated; the joint gradually becomes stiff and painful. This is known as knee osteoarthritis or gonarthrosis.

When should a distal femoral osteotomy be considered?

A distal femoral osteotomy is indicated when only the lateral femorotibial compartment of the knee is affected by osteoarthritis. A knock-knee deformity of the femur (genu valgum) can aggravate this osteoarthritis, as it increases the load on the lateral compartment of the knee and accelerates cartilage wear.

A distal femoral osteotomy is only indicated when the cartilage in the lateral part of the knee is not completely worn in patients under 60 who are considered too young to undergo a knee replacement.

This procedure consists in straightening the deformity of the femur to transfer the mechanical load to the medial part of the knee where the cartilage is not worn thus relieving the pain in the lateral part of the knee, slowing the progression of osteoarthritis, and ultimately delaying the need for a knee replacement.

This procedure is sometimes proposed in the absence of significant pain in relatively young patients with severe lateral osteoarthritis. The problem with this type of osteoarthritis is the risk of it becoming painful once the cartilage wear is too severe and a distal femoral osteotomy is no longer possible. This procedure may, therefore, be proposed in young patients to slow the progression of the osteoarthritis and avoid a knee replacement, even in the absence of pain.

Before the operation

A distal femoral osteotomy requires an operation. The realignment necessary is determined during a scheduled consultation based on x-rays of all the lower limbs (hip-knee-ankle x-ray or EOS scan).

Before the operation, a pre-anaesthesia consultation is conducted to check the patient is physically apt to undergo the operation and minimise the risk of postoperative complications.

The operation

The operation takes place in an operating theatre in compliance with strict standards of cleanliness and safety. The patient is placed supine on an operating table and a tourniquet is placed around the thigh. The operation lasts about 1 hour and can be carried out under general or spinal anaesthesia. The latter is a regional anaesthetic anaesthetising the lower part of the body (as with an epidural). The anaesthetist will decide on the most suitable anaesthetic together with the patient.

To perform a distal femoral osteotomy, an incision about 10 centimetres long on the lower, medial part of the thigh is necessary. Two cut lines are made in the femur and a wedge of bone is removed to realign the axis of the knee. The femur is then fixed with a plate.

After the operation

A drain is inserted in the incision to prevent the formation of a haematoma.

After the operation, the knee is partially numbed with a nerve block to help improve postoperative pain management.

The effect lasts approximately 18 hours after the operation and can be prolonged with the insertion of a catheter in the thigh if the anaesthetist considers it necessary. Medication and ice on the knee also provide effective postoperative pain management.

After the operation, weight-bearing is not allowed on the leg operated on for 6 weeks and crutches must be used for walking.

Weight-bearing can then be resumed gradually. During this period, the knee can be mobilised during rehabilitation sessions. The knee may be immobilised in a brace while the bone heals.

The stay in hospital is often between 2 and 5 days.

The bone takes 2 to 3 months to heal, sometimes longer.

Several appointments are necessary to monitor the healing of the osteotomy.

The duration of medical leave depends on the patient’s occupation and is often between 2 and 4 months.

Driving can be resumed once weight-bearing is fully recovered. Sport can generally be resumed after 6 months.

Planning osteotomy lines (in red)
Planning osteotomy lines (in red)
Femoral cutting guide
Femoral cutting guide
Final appearance with femur realignment
Final appearance with femur realignment

Risks linked to the operation

Unfortunately, zero risk does not exist in surgery. Any operation has its risks and limitations, which you must accept or not undergo the operation. However, if an operation is proposed, the surgeon and the anaesthetist consider that the expected benefits far outweigh the risk incurred.

Some risks, such as microbial infections of the surgical site, are common to all types of surgery. Fortunately, this complication is rare but when it occurs requires another operation and a course of antibiotics.
Bruising can also appear around the surgical site. This is usually prevented or reduced with a suction drain inserted at the end of the operation and removed in the days following the operation.

Knee surgery and lack of weight-bearing on the limb operated on also increase the risk of phlebitis, which can lead to a pulmonary embolism. To minimise this risk, blood thinners (in the form of daily injections or tablets) are prescribed until weight-bearing is resumed, in other words, for 6 weeks after the operation.

Failure of the osteotomy to fuse after 6 months is called nonunion and requires further surgery for the femur to heal.

In rare cases, the knee remains stiff, hot, and painful for several months after the operation. This complication, known as algodystrophy or Chronic Regional Pain Syndrome (CRPS), is unpredictable and sometimes takes a long time to heal.

Finally, rarer complications can also occur. Blood vessels (arteries, veins) can be accidentally damaged and will require vascular surgery (bypass). Nerves can also be damaged accidentally during the operation with a risk of paralysis or loss of feeling in the limb operated on, which can be transitory or permanent.

If you have any concerns about the operation, do not hesitate to talk to your surgeon or the anaesthetist and they will answer any questions you may have.

In summary...

When is surgery necessary?

In the case of lateral knee osteoarthritis in young patients (< 60 years)

Aim of the operation

Relieve the pain and slow the progression of osteoarthritis

Which anaesthesia?

General or regional (determined with the anaesthetist)

Duration of hospitalisation

Between 2 and 5 days

Resumption of weight-bearing

6 weeks after the operation

After the operation

Return home

Duration of rehabilitation

Generally 2 to 3 months

Duration of medical leave

2 to 4 months

Resumption of car driving

1 ½ months after the operation, once weight-bearing has been resumed

Resumption of sport

6 months after the operation

Make an appointment

If you have any questions or wish to book a consultation,
please do not hesitate to contact us or make an appointment online via DoctoLib
Scroll to Top