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. 2022 Jun 21;11(6):e1105–e1109. doi: 10.1016/j.eats.2022.02.023

Table 2.

Pearls and Pitfalls of Double-Level Osteotomy

Pearls and Pitfalls DFO Surgical solution
Hinge fracture
  • 1.

    Hinge position: directly on femoral condyle, 5 to 10 mm from contralateral cortex

  • 2.

    Hinge protection: hinge wire

  • 3.

    Cut till the end by if necessary removal of inferior wedge K-wire and then place the hinge wire to limit the wedge towards hinge

  • 4.

    Hinge closure under clearance with oscillating saw

  • 5.

    Hinge stabilization with thigh pillow to prevent posterior fall back after osteotomy due to weight of limb

  • 6.

    Do not accept macroscopic fractures, bilateral plating is safer
Neurovascular damage
  • 1.

    Safe cutting due to posterior clearance with periosteal elevator

  • 2.

    Finger guided saw blade

  • 3.

    Special radiolucent retractors
Cutting precision
  • 1.

    Placing only 1 K-wire for each wedge cut is sufficient and easier to aim

  • 2.

    K-wires with drill tip

  • 3.

    Wires need to be parallel (cave: parallax)
Rotational malalignment Perform biplanar DFOs
Implant malpositioning Perform a proximal and distal K-wire transfixation and check lateral x-ray film before screw insertion
Delayed union Compress every closed wedge surgery
Pearls and Pitfalls HTO Surgical solution
Hinge fracture
  • 1.

    Hinge position in “safe zone“

  • 2.

    Cut below the K-wire to avoid intraarticular Takeuchi 3 fractures

  • 3.

    Avoid inferior saw-blade divergence from K-wire to prevent Takeuchi 2 fractures

  • 4.

    Place a hinge wire to protect the hinge and prevent overcutting

  • 5.

    Do not open against high restraint forces

  • 6.

    Make sure to have cut the posterior cortex completely
Neurovascular damage
  • 1.

    Place the retractor posterior to the MCP in a two-window technique

  • 2.

    Check the retractor sits directly between dorsal cortex and popliteus muscle

  • 3.

    Control the retractor alignment with regards to the K-Wire fluoroscopically
MCL over-tensioning
  • 1.

    Place an osteotomy spreader dorsal to the MCL and check the MCL with forceps after opening the gap

  • 2.

    Release if needed e.g. pie crust
Slope change
  • 1.

    Avoid opening the osteotomy against the restraint from the MCL with the spreader anterior to it (Slope elevation-the reason for the often-accused change of slope in owHTO-technical error)

  • 2.

    Create a triangular osteotomy gap with higher posterior opening

DFO, distal femoral osteotomy; HTO, high tibial osteotomy.