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Information for Distal Femoral Osteotomy Patients

Knocked Knee

Diagram showing a straight (balanced) knee on the left and a valgus or “knock-kneed” leg on the right. Note that the weight bearing axis, seen as a dotted line, goes through the outside part of the valgus knee—leading to a weight imbalance (represented by the orange lines).

A painful osteoarthritic knee in a middle–aged recreational patient is one of the most difficult problems to manage. Initially, all patients should be treated conservatively; however, when pain worsens as the osteoarthritis progresses, surgical treatment should be considered. There are two major types of osteoarthritis in the middle–aged or younger athlete: post–traumatic and non–traumatic. Post–traumatic osteoarthritis occurs in patients who have had a previous knee injury as a young adult and may have had their meniscus, or part of it removed surgically. Non–traumatic osteoarthritis occurs in patients who have not had a previous knee injury and in whom the osteoarthritis is strongly genetically determined. Such patients often report a family history of early osteoarthritis.

Another common finding in patients with either a post-traumatic or genetically related osteoarthritis is a malalignment of the lower extremity. The malalignment also can be either acquired or congenitial. The malalignment of the leg is commonly referred to being “bow–legged” or “knock-kneed”. In orthopedics, we use the term varus to describe a bow-legged knee and the term valgus when referring a knock–kneed deformity. This section is dedicated to explaining the treatment of those younger patients patients with significant damage to the outside, or lateral part of the knee. Damage in the lateral joint of the knee frequently occurs in those patients with valgus knees.

Symptoms and Signs

The predominant symptoms of osteoarthritis of the knee are pain, swelling, stiffness and a decreased pain-free activity level. The pain generally worsens with activities and improves with rest. Commonly, wasting of the thigh muscle occurs. This in turn may increase pain and may also cause symptoms of giving way. Symptoms such as locking and catching may also be present.

Treatment Options

Conservative treatments, such as bracing, physical therapy, activity modification, and analgesic medication have a role in treatment. Unfortunately, many of these modalities will not prevent the ultimate development of arthritis, or damage to the articular cartilage in the knee. If the patient is nearing the age of 60, it is worth considering continuing with conservative measures for as long as possible so that when complete deterioration of the joint has occurred, joint replacement may be performed.

An osteoarthritic knee in a young patient is a difficult problem to manage. For this reason, younger and middle aged patients may be best treated with an osteotomy. Osteotomy surgery is most successful when performed during the early stages of osteoarthritis. Only certain patients will respond well to osteotomy, therefore Dr. Lyman will carefully consider whether you are a likely successful candidate.

Osteotomy is an appropriate surgical option in selected cases of arthritis affecting one side of the knee only. The purpose of an osteotomy is to transfer a percentage of the weightbearing load to an uninvolved joint surface. The damaged side of the joint is no longer smooth and free running and this leads to stiffness and pain.

Femoral osteotomies may be indicated for patients with:

It should be stressed that an osteotomy is designed to allow patients to walk without discomfort, not to return them to sporting activities.

If adequate correction is achieved, the success rate of distal femoral osteotomy is high. Those patients who fail to achieve long-term relief usually obtain at least a few years of relief and are then eligible for joint replacement. Osteotomy is strongly recommended for the middle-aged patient with osteoarthritis.

What is Involved for You as the Patient

After Your Surgery
When you wake after surgery you will be in the recovery room. There will be a brace on your leg and an ice machine or ice pack. In the recovery room, the brace will be removed briefly for routine x-rays. You may not remember getting these done as you may be quite drowsy.

From here you will be transferred back to your room. You will be given regular pain relief by the nursing staff in the form of an injection or tablet as required. Your condition will be monitored closely.

A physiotherapist will visit you in the afternoon of your surgery, or the following day. They will show you some exercises for your leg and get you up for a walk. You will begin walking with crutches or a walking frame and will need to avoid putting full weight through your operated leg. Once you are able to safely mobilize and care for yourself you will be discharged from hospital, usually 2-3 days following your surgery.

After Your Hospital Stay
You will receive instructions from the nursing staff prior to being discharged from hospital. However, it is usual to be reviewed at 2 weeks after surgery for removal of the dressings and checking of your brace. The brace will be on for a further 4 weeks at which time it will be removed at the 6-week review appointment. At 3-4 weeks after surgery you may begin to take partial weight through your operated leg, as pain allows. Dr. Lyman will choose an appropriate blood thinner, usually either aspirin or Warfarin, depending on your blood clots risk factors. Dr Lyman will review you at 6 and 12 weeks after surgery.

Potential Complications Related to Surgery

  1. Pneumonia—After any general anesthetic there is always a risk of developing a chest infection. This risk can be minimized by early mobilization and performing deep breathing exercises after surgery. If you have any history of respiratory problem you should inform the staff at the hospital.
  2. Deep Vein Thrombosis and Pulmonary Embolus—A combination of surgery, immobilization of the limb, smoking and the oral contraceptive pill or hormonal replacement therapy all multiply to increase the risk of a blood clot. Any past history of blood clots should be brought to the attention of the surgeon prior to your operation. The oral contraceptive pill, hormonal replacement therapy and smoking should cease one week prior to surgery to minimize the risk.
  3. Excessive bleeding resulting in a haematoma is known to occur with patients taking aspirin or anti-inflammatory drugs-such as Voltaren, Naprosyn or Indocid. They should be stopped at least one week prior to surgery.
  4. Infection—Surgery is carried out under strict germ free conditions in an operating theatre. Antibiotics are administered intravenously at the time of your surgery. Any allergy to any known antibiotics should be brought to the attention of your surgeon or anaesthetist. Despite these measures, following surgery there is a less than 3% chance of developing an infection. Most commonly these are superficial wound infections that resolve with a course of antibiotics. More serious infections may require further hospitalization and treatment.
  5. Neurovascular Injury—Injury to the peroneal nerve can occur in patients following high tibial osteotomy. This may result in sensory loss or muscle impairment (example: footdrop). Most patients recover without any permanent functional disability. Injury to the blood vessels around the knee during surgery is a very rare complication (less than 1%).
  6. Delayed or Non-Union of the Osteotomy—Failure of the bone to heal, which occurs sporatically with some fractures, may occur in 2 to 4% of cases. If this does, it may require a second surgery. If your insurance allows, Dr. Lyman will prescribe a bone stimulator to decrease the chance of this complication. Other potential problems include postoperative stiffness, pain and wound problems.

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Last Modified: June 24, 2014