I'm not going to make the moderator state, but I would suspect that for the standard valgus knee, they're going on the femur, not the tibia. And I would bet that most people in this room are doing the same. So I'm going to tell you in five minutes why distal femoral osteotomy is better. And I agree, high tibial versus proximal tibia, it's an interesting concept. But I'm going with the HDO. My disclosures are available online, and you can see them all in the program. So the valgus knee, we all know about the valgus knee. No one wants a valgus knee because it results in the problems that you see here in the lateral compartment, which can be devastating to treat, make all of us get a little bit nauseous. And so there's a lot of different osteotomy options for the valgus knee, including everything you see here, two options on the femur, two options on the tibia. And I would argue that for the vast majority of patients, you can accomplish everything you need to on the femur without having the risks and complications and potentially negative outcomes that you might have on the tibia. As surgeons, we want good outcomes. Distal femoral osteotomy checks that box. As surgeons, we want to avoid unnecessary complications. Doing this on the tibia creates a lot of potential extra complications. And finally, we want good outcomes. And doing this on the femur allows you good outcomes. What should you choose? Well I will say this is not a one-size-fits-all solution. There's no single right answer. You need to treat each patient individually because all of the approaches have advantages and disadvantages. And certainly you need to understand where the deformity is. If the deformity is in the tibia, you should treat the tibia. But that's just the minority of cases. So when we're talking in a room like this and we're teaching the vast majority of surgeons who do osteotomies, we need to understand what the vast majority of surgeons will use. And that's going to be a simple approach on the femur. We need to understand how much correction is needed. There's only so much bone on the tibia that you can manage before you're going to destroy the joint line with respect to obliquity. And then you have no ability to correct the patient's deformity. And then what about additional procedures? If you're doing cartilage restoration, meniscus transplantation, wouldn't a single approach on the lateral side of the femur be more ideal than multiple incisions across the knee that may very well need a total knee replacement in the future anyway? So while there's no single right answer, what should you choose? Distal femoral osteotomy. Three pearls in my three minutes that are remaining as to why you should choose this. Number one, DFO is versatile. A lateral opening wedge, which is probably the workhorse for the vast majority of surgeons, at least in the U.S., is great for large corrections up to 14 or 15 degrees. You can really make a nice osteotomy using that standard, straightforward lateral approach to the femur. It also gives you excellent access for concomitant procedures as I mentioned, meniscus transplantation, cartilage restoration, ACL reconstruction, lateral-sided augmentation for your ACL reconstruction, et cetera. And then on the medial side, if you're doing small to medium or even large corrections, you can go on the medial side with an inherent stable construct and you can have immediate weight bearing, which is really nice. So it gives you versatile options. Pearl number two, distal femoral osteotomy is safe and efficient. This is a single incision to do a single task and it's familiar for us as surgeons. These can be stressful cases, at least maybe for me, maybe not for the experts in this room. But they can be stressful cases. Let's minimize the stress level in the room with a single incision, a single approach on the lateral side or the medial side. When you go down to the tibia, you've got a lot of things you've got to worry about. First and foremost, you can create iatrogenic excessive joint line obliquity. Second, if you're going on the lateral side, which many people like to do, you may have to perform a fibular osteotomy. We came here to cut one bone and one bone only. We do not need to cut two bones to accomplish this task. And then you also have the risk of the perineal nerve. I don't want to look at that nerve if I don't have to. I don't want to think about that nerve. In fact, thinking about it right now is making my heart rate go up. Why would I want to introduce that potential complication in the operating room? Pearl number three, DFO has terrific outcomes. Now no surgery we do in orthopedics is perfect and certainly osteotomy is not perfect. But when you look at the literature, the outcomes for both medial closing wedge and lateral opening wedge distal femoral osteotomy are terrific with respect to improving pain and improving functional abilities of these patients. Recent 2023 systematic review really showed or highlighted the literature with respect to this, with all the literature to date. Now my opponent might say, and you've heard this, and he elegantly describes some of the problems, DFO only really offloads the lateral compartment and extension. And that's true. This is not a flexion offloading procedure. However, most patients undergoing a DFO have a hypoplastic lateral femoral condyle. They're going to have challenges in extension more than flexion. This truly is a workhorse for the vast majority of patients with valgus. And they might also, Neil might also say that you get hardware irritation, malunion, nonunion. All happens on the tibia as well. And depending on the amount of bone that you take happens quite a bit. So there's no free lunch as one of my mentors would say. And everything we do has potential problems. But I would argue that the problems on the femur are much less than the problems on the tibia. Be careful with an HTO for valgus. This is really only useful for smaller corrections. You've got to worry about that joint line. You've got to be prepared to deal with the other things that I mentioned including the fibula and the perineal nerve. And I applaud Travis Mack who was kind enough to show me a case example. He had this very difficult case, deformity on the tibia. He did an appropriate and perfectly executed tibial osteotomy, but look at the joint line. Now the patient's doing well, but we have to follow this over time, particularly for our young patients. So you've got to be careful. And the outcomes are not that good. If you look at the papers that look at proximal tibia osteotomy for valgus, you'll see 60%, 70%, maybe 72% successful outcomes. And when you look at the definition of success in those papers, it's good to very good. We don't even see the word excellent. So it can be challenging to understand how this is a good procedure for the vast majority of patients. So take-home points, DFO is a workhorse for the vast majority of valgus patients. You can do big corrections. You can do small corrections. It's safe. It's simple. It's familiar. It's the easiest technique to optimize your outcomes while minimizing your complications. Thank you.

distal femoral osteotomy

valgus knee

osteotomy procedures

femur

tibial osteotomy