The Outcomes of Distal Femoral Varus Osteotomy in Patellofemoral Instability: A Systematic Review and Meta-Analysis

Si Heng Sharon Tan; Si Jian Hui; Chintan Doshi; Keng Lin Wong; Andrew Kean Seng Lim; James Hoipo Hui

doi:10.1055/s-0039-1681043

The Journal of Knee Surgery, Table of Contents

J Knee Surg 2020; 33(05): 504-512
DOI: 10.1055/s-0039-1681043

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Outcomes of Distal Femoral Varus Osteotomy in Patellofemoral Instability: A Systematic Review and Meta-Analysis

Si Heng Sharon Tan

¹Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore, Singapore

,

Si Jian Hui

¹Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore, Singapore

,

Chintan Doshi

¹Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore, Singapore

,

Keng Lin Wong

¹Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore, Singapore

,

Andrew Kean Seng Lim

¹Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore, Singapore

,

James Hoipo Hui

¹Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore, Singapore

› Author Affiliations

Abstract

Distal femoral varus osteotomies have been novelly described in the recent years to be successful in the management of patellofemoral instability with genu valgum. However, these publications are limited to case reports and small case series and no published literature have attempted to analyze them in totality. The current review aims to pool together these small case series to evaluate the outcomes and complications of distal varus femoral osteotomies when performed for patellofemoral instability. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. All studies that reported the outcomes of distal femoral varus osteotomy for patellofemoral instability were included. A total of five publications were included in the review, which included a total of 73 patients. All of the studies reported improvement in the radiological outcomes for genu valgum correction and patellofemoral instability. One study using opening wedge osteotomy reported a decrease in Caton–Deschamps index postoperatively, while another study using closing wedge osteotomy reported maintenance of the Caton–Deschamps index postoperatively. Second look arthroscopy showed an improvement in the status of the chondral lesions of the medial facet of the patellar undersurface, the lateral facet of the patellar undersurface and the trochlear groove 2 years postoperatively. All studies also reported a decrease in the risk of recurrence of patellofemoral instability, reduction in pain, and an improvement in all the clinical outcomes knee scores. Distal femoral varus osteotomy is promising and useful in the management of patellofemoral instability with genu valgum. The procedure can allow for radiological correction of the genu valgum and patellofemoral instability, reduction in the risk of recurrence of patellofemoral instability, reduction in pain, improvement in clinical knee outcome scores, and improvement in the status of the chondral lesions in the patellofemoral joint. It is highly versatile and could accommodate varying degrees of correction. These improvements in radiological and clinical outcomes can be seen in studies for both closing wedge and opening wedge distal femoral osteotomies. However, opening wedge osteotomies appear to decrease the patellar height as compared with closing wedge osteotomies which maintain the patellar height; therefore, the patellar height should be assessed preoperatively prior to deciding whether to perform an opening wedge or closing wedge distal femoral varus osteotomy. The Level of Evidence for this study is IV.

Keywords

patellar instability - patellofemoral instability - genu valgum - distal femoral varus osteotomy - femoral osteotomy - varus osteotomy

Full Text

References

References
1 Colvin AC, West RV. Patellar instability. J Bone Joint Surg Am 2008; 90 (12) 2751-2762
2 Tan SHS, Ibrahim MM, Lee ZJ, Chee YKM, Hui JH. Patellar tracking should be taken into account when measuring radiographic parameters for recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc 2018; 26 (12) 3593-3600
3 Tan SHS, Tan LYH, Lim AKS, Hui JH. Hemiepiphysiodesis is a potentially effective surgical management for skeletally immature patients with patellofemoral instability associated with isolated genu valgum. Knee Surg Sports Traumatol Arthrosc. 2018. doi: 10.1007/s00167-018-5127-8
4 Tan SHS, Chng KSJ, Lim BY, Wong KL, Doshi C, Lim AKS, Hui JH. The Difference between Cartilaginous and Bony Sulcus Angles for Patients with or without Patellofemoral Instability: A Systematic Review and Meta-analysis. J Knee Surg. 2019. doi: 10.1055/s-0038-1677541
5 Redziniak DE, Diduch DR, Mihalko WM. , et al. Patellar instability. J Bone Joint Surg Am 2009; 91 (09) 2264-2275
6 Kearney SP, Mosca VS. Selective hemiepiphyseodesis for patellar instability with associated genu valgum. J Orthop 2015; 12 (01) 17-22
7 Chang CB, Shetty GM, Lee JS, Kim YC, Kwon JH, Nha KW. A combined closing wedge distal femoral osteotomy and medial reefing procedure for recurrent patellar dislocation with genu valgum. Yonsei Med J 2017; 58 (04) 878-883
8 Dickschas J, Ferner F, Lutter C, Gelse K, Harrer J, Strecker W. Patellofemoral dysbalance and genua valga: outcome after femoral varisation osteotomies. Arch Orthop Trauma Surg 2018; 138 (01) 19-25
9 Nha KW, Ha Y, Oh S. , et al. Surgical treatment with closing-wedge distal femoral osteotomy for recurrent patellar dislocation with genu valgum. Am J Sports Med 2018; 46 (07) 1632-1640
10 Swarup I, Elattar O, Rozbruch SR. Patellar instability treated with distal femoral osteotomy. Knee 2017; 24 (03) 608-614
11 Wilson PL, Black SR, Ellis HB, Podeszwa DA. Distal femoral valgus and recurrent traumatic patellar instability: is an isolated varus producing distal femoral osteotomy a treatment option?. J Pediatr Orthop 2018; 38 (03) e162-e167
12 Omidi-Kashani F, Hasankhani IG, Mazlumi M, Ebrahimzadeh MH. Varus distal femoral osteotomy in young adults with valgus knee. J Orthop Surg Res 2009; 4: 15
13 Kwak JH, Sim JA, Kim NK, Lee BK. Surgical treatment of habitual patella dislocation with genu valgum. Knee Surg Relat Res 2011; 23 (03) 177-179
14 Purushothaman B, Agarwal A, Dawson M. Posttraumatic chronic patellar dislocation treated by distal femoral osteotomy and medial patellofemoral ligament reconstruction. Orthopedics 2012; 35 (11) e1668-e1672
15 Kwon JH, Kim JI, Seo DH, Kang KW, Nam JH, Nha KW. Patellar dislocation with genu valgum treated by DFO. Orthopedics 2013; 36 (06) 840-843
16 Yoshvin S, Southern EP, Wang Y. Surgical treatment of congenital patellar dislocation in skeletally mature patients: surgical technique and case series. Eur J Orthop Surg Traumatol 2015; 25 (06) 1081-1086
17 Suzuki A, Kimura Y, Sasaki E, Narita A, Takagi M, Ishibashi Y. Recurrent patellar dislocation with spontaneous valgus knee deformity treated by distal femoral osteotomy alone: A report of two cases. J Orthop Sci 2017; S0949-2658(17)30216-6
18 Hinterwimmer S, Minzlaff P, Saier T, Niemeyer P, Imhoff AB, Feucht MJ. Biplanar supracondylar femoral derotation osteotomy for patellofemoral malalignment: the anterior closed-wedge technique. Knee Surg Sports Traumatol Arthrosc 2014; 22 (10) 2518-2521
19 Sabbag 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 2017; 6 (06) e2085-e2091
20 Shen HC, Chao KH, Huang GS, Pan RY, Lee CH. Combined proximal and distal realignment procedures to treat the habitual dislocation of the patella in adults. Am J Sports Med 2007; 35 (12) 2101-2108
21 Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results fromseveral studies in meta-analysis. In Egger M, Smith GD, Altman DG, eds. Systematic Reviews in Health Care: Meta-analysis in Context. 2nd ed. London: BMJ Publishing Group; 2001:285–312
22 Fleiss JL. The statistical basis of meta-analysis. Stat Methods Med Res 1993; 2 (02) 121-145
23 Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327 (7414): 557-560
24 Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21 (11) 1539-1558
25 Whitehead A. (2002). Meta-Analysis of Controlled Clinical Trials. West Sussex: John Wiley and Sons, Ltd.; 2002
26 Stevens PM, Maguire M, Dales MD, Robins AJ. Physeal stapling for idiopathic genu valgum. J Pediatr Orthop 1999; 19 (05) 645-649
27 Paley D. Normal lower limb alignment and joint orientation. Princ Deform Correct 2002; 1: 1-18
28 Sabzevari S, Ebrahimpour A, Roudi MK, Kachooei AR. High tibial osteotomy: a systematic review and current concept. Arch Bone Jt Surg 2016; 4 (03) 204-212
29 Inoue M, Shino K, Hirose H, Horibe S, Ono K. Subluxation of the patella. Computed tomography analysis of patellofemoral congruence. J Bone Joint Surg Am 1988; 70 (09) 1331-1337
30 Hinckel BB, Gobbi RG, Filho EN. , et al. Are the osseous and tendinous-cartilaginous tibial tuberosity-trochlear groove distances the same on CT and MRI?. Skeletal Radiol 2015; 44 (08) 1085-1093
31 Caton J, Mironneau A, Walch G, Levigne C, Michel CR. [Idiopathic high patella in adolescents. Apropos of 61 surgical cases]. Rev Chir Orthop Repar Appar Mot 1990; 76 (04) 253-260
32 Kim 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 2018; 30 (01) 3-16
33 Bin SI, Kim HJ, Ahn HS, Rim DS, Lee DH. Changes in patellar height after opening wedge and closing wedge high tibial osteotomy: a meta-analysis. Arthroscopy 2016; 32 (11) 2393-2400