Morphological Analysis of the Distal Femur as a Surgical Reference in Biplane Distal Femoral Osteotomy

Morphological Analysis of the Distal Femur as a Surgical Reference in Biplane Distal Femoral Osteotomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Morphological Analysis of the Distal Femur as a Surgical Reference in Biplane Distal Femoral Osteotomy Shohei Sano, Takehiko Matsushita, Naosuke Nagata, Takeo Tokura, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3932959/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Distal femoral osteotomy (DFO) is performed alone or with high tibial osteotomy (HTO) for patients with osteoarthritis and distal femur deformities. DFO is technically demanding, particularly when creating an anterior flange. Herein, we examined the morphological characteristics of the distal femur based on the cortical shape as a surgical reference for biplanar DFO. Computed tomography images of 50 valgus and 50 varus knees of patients who underwent biplanar DFO or total knee arthroplasty were analyzed. Axial slices at the initial level of the transverse osteotomy in the DFO and slices 10 mm proximal and 10 mm distal to that level were selected. The medial and lateral cortical angles and heights (MCLA, LCLA, MCH, and LCH) were measured on axial slices. Statistical comparisons were performed between the medial and lateral cortices and valgus and varus knees. MCLA and MCH were significantly smaller and lower, respectively, than LCLA and LCH (P < 0.01). The MCLA and MCH of varus knees were significantly smaller and lower, respectively, than those of valgus knees (P < 0.01). Surgeons should carefully observe morphological differences in the distal femur cortex, distinguishing between medial and lateral knees and varus and valgus knees during the creation of the anterior flange in the DFO. Health sciences/Anatomy/Musculoskeletal system Health sciences/Health care/Medical imaging/Bone imaging Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Distal femoral osteotomy (DFO) is a surgical procedure used alone or in combination with proximal tibial osteotomy to treat patients with lower-limb malalignment 1–9 . Medial closing wedge DFO (MCWDFO) is performed in patients with valgus knee osteoarthritis (OA) 3,5,8,10–13 , whereas lateral closing wedge DFO (LCWDFO) is performed in conjunction with high tibial osteotomy (HTO) to treat severe varus knee OA, creating a double-level osteotomy (DLO) 14–19 . Regarding surgical techniques, biplanar osteotomy has gained popularity in HTO and DFO. Its widespread adoption is attributed to its advantages, such as a large contact area and better stability against axial load 20,21 . In addition, the biplanar osteotomy technique offers the advantage of effectively reducing fragments in hinge fractures. The anterior flange can be used to control fragment rotation during the procedure. Although the biplanar osteotomy technique offers such advantages, it is more technically challenging than single-plane osteotomy. In biplanar DFO, careful attention is required to determine the osteotomy angle and thickness when creating the anterior flange. A higher incidence of hinge fractures occurs after MCWDFO than after LCWDFO via DLO 22 . Upon reviewing our previous cases of DFO, we observed a higher occurrence of hinge fractures in patients who underwent MCWDFO than in those who underwent LCWDFO due to an excessively thick anterior flange. This resulted in a substantial decrease in the width of the opposite hinge compared to those who underwent LCWDFO (Fig. 1 ). This difference appears to be attributable to anatomical differences between the medial and lateral cortices. Familiarity with the anatomical shape of the distal femur is crucial for accurately forming the anterior flange in biplanar DFO. However, details of the distal femoral bony morphology for distal femoral osteotomy have not been reported. We hypothesized that the distal femoral cortex is shorter and more inclined on the medial side than on the lateral side and that the distal femoral cortex of valgus knees is smaller and more inclined than that of varus knees. This study aimed to examine the morphological characteristics of the bony cortex of the distal aspect of the femur by comparing valgus and varus knees. Materials and methods Patients In total, 100 knees of 97 patients who underwent DFO or total knee arthroplasty (TKA) between February 2018 and March 2022 at our institution were included in this study. To analyze valgus knee OA, 50 knees of 49 patients who underwent TKA or DFO for this condition were selected. To analyze varus knees, 50 knees from 48 patients who underwent HTO or DLO for this condition were selected (Table 1 ). This retrospective study was approved by the Institutional Review Board of our institution, and written informed consent was obtained from all patients before their enrollment. Table 1 Patient demographic, surgical, and radiographic data. Valgus (n = 50) Varus (n = 50) P value Patient demographics Age (years) 66.0 ± 16.5 60.5 ± 6.9 < 0.01 Gender (male/female) 16/34 30/20 < 0.01 Height (cm) 157.7 ± 10.3 163.9 ± 8.0 < 0.01 Weight (kg) 61.9 ± 12.4 70.4 ± 11.2 < 0.01 BMI (kg/m²) 24.8 ± 3.5 26.2 ± 3.6 < 0.05 Radiographic evaluation Preoperative FTA (°) 165.8 ± 7.2 180.4 ± 2.8 < 0.01 Preoperative %MA (%) 88.9 ± 30.3 20.5 ± 13.6 < 0.01 Evaluation of surgical procedures TKA/Osteotomy (n) 35/15 0/50 < 0.01 Mono-plane/Bi-plane (n) 6/9 9/4 n.s n , number of knees; FTA. femorotibial angle; MA , mechanical axis; n.s , not significant Table 2 Comparison between MCLA and LCLA in valgus and varus knees. MCLA (°) LCLA (°) P value Valgus 10 mm proximal 69.2 ± 8.5 79.1 ± 4.8 < 0.01 Reference 68.1 ± 8.5 78.4 ± 4.3 < 0.01 10 mm distal 67.0 ± 7.5 79.5 ± 4.4 < 0.01 Varus 10 mm proximal 75.2 ± 6.7 81.3 ± 4.1 < 0.01 Reference 74.8 ± 5.9 80.4 ± 4.7 < 0.01 10 mm distal 71.8 ± 5.3 81.2 ± 4.5 < 0.01 Values are the mean ± standard deviation. Inclusion and exclusion criteria The inclusion criteria were as follows: ( 1 ) patients who underwent TKA or knee osteotomy (DFO, HTO, DLO) and ( 2 ) those who underwent plain computed tomography prior to surgery. The exclusion criteria were as follows: ( 1 ) severe post-traumatic deformity, ( 2 ) post-infectious knee arthritis, and ( 3 ) rheumatoid arthritis. Surgical indication The indications for MCWDFO were lateral compartment OA with cartilage damage, patellar dislocation with a mechanical lateral distal femoral angle (mLDFA) ≤ 85°, and % mechanical axis (MA) ≥ 55%; HTO was recommended for patients with medial knee OA. DLO was performed if a medial opening gap > 20 mm was required or if the mechanical proximal angle exceeded 95° after correction to achieve the target alignment in preoperative planning. DLO was also performed in patients with an mLDFA ≥ 90°. Indications for TKA for valgus knee OA are low activity levels and severe knee deformities. Measurements Measurement level Axial CT images were used for these measurements. An axial slice 65 mm proximal to the knee joint line, which corresponds to 40 mm proximal to the medial or lateral epicondyle, served as the primary reference level. The slice position was selected based on the average starting level of the transverse osteotomy in patients who underwent DFO at our hospital. Subsequently, the cortex angle and height were measured on the reference slice, along with slices positioned 10 mm proximal and 10 mm distal to the reference slice. Angle First, a straight line was drawn along the posterior margin of the femur (Line 1). Second, we drew a line parallel to Line 1 through the front tip of the femur (Line 2). Third, we drew a line between the middle of Lines 1 and 2 (Line 3) and determined the intersection of the inside and outside (A, B). Fourth, tangential lines were drawn through Point A to the medial cortex (Line 4) and through Point B to the lateral cortex (Line 5). Fifth, the angle between Line 1 and Line 4 was defined as the medial cortex line angle (MCLA), and the angle between Line 1 and Line 5 was termed the lateral cortex line angle (LCLA) (Fig. 2 ). Height First, tangential lines were drawn to the inside of the posterior cortex (Line 6) and anterior cortex (Line 7). Second, a vertical line was drawn from Lines 6 to 7, with the inner intersection point as Point M and the outer intersection point as Point L. Third, the vertical distance between Line 6 and Point M was defined as the medial cortex height (MCH), and that between Line 7 and Point L was defined as the lateral cortex height (LCH) (Fig. 3 ). Statistical analyses The number of samples was determined based on a priori sample size calculations. A priori power analysis using G*Power (Heinrich Heine Universitȁt Dȕsseldorf, Germany) indicated a minimum of 47 samples for each group to detect a difference between the two groups with an alpha level of 0.05, a beta of 80%, and an effect size of 0.58. Considering the error margin, the sample size was set to 50 for each group. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (R Foundation for Statistical Computing, Vienna, Austria) 23 . The normality test was the Shapiro–Wilk test. Owing to the normality of the data, the Mann-Whitney U test or Student t-test was used to compare continuous values between the two groups. Fisher’s exact test was used to compare categorical values. Statistical significance was set at P < 0.05. The inter-class correlation coefficient (ICC) was used to assess inter-rater and intra-rater reliability for MCLA, LCLA, MCH, and LCH. ICC < 0.50 was considered poor reliability, 0.50 ≤ ICC < 0.75 was considered moderate reliability, 0.75 ≤ ICC < 0.90 was considered good reliability, and ICC ≥ 0.90 was considered excellent reliability 24 . Results Validation of measurement methods for distal femur shape The ICC values for each angle and height (MCLA, LCLA, MHC, and LCH) are summarized in Supplemental Table 1. Overall, good-to-excellent intra-rater reliability was obtained for MCLA, LCLA, MHC, and LCH. Similarly, good-to-excellent ICC values for inter-rater agreement were obtained (Supplemental Table 1). Comparison of the cortex angle between the medial and lateral side of the distal femur in valgus and varus knees The mean MCLA was significantly smaller than the LCLA in both valgus and varus knees at all three levels (P < 0.01) (Table. 2). Comparison of cortex height between the medial and lateral side of the distal femur in valgus and varus knees The mean LCH was significantly higher than the mean MCH in the valgus and varus knees at all three levels (P < 0.01) (Table 3 ). Table 3 Comparison between MCH and LCH in valgus and varus knees. MCH (mm) LCH (mm) P value Valgus 10 mm proximal 20.4 ± 3.5 26.4 ± 3.6 < 0.01 Reference 21.3 ± 3.5 27.3 ± 3.8 < 0.01 10 mm distal 23.5 ± 4.0 29.5 ± 4.5 < 0.01 Varus 10 mm proximal 23.7 ± 3.1 29.4 ± 3.3 < 0.01 Reference 24.7 ± 3.1 30.3 ± 3.3 < 0.01 10 mm distal 27.1 ± 3.4 32.7 ± 3.5 < 0.01 Values are the mean ± standard deviation. Comparison of cortex angle and height between valgus and varus knees The mean MCLA in valgus knees was significantly smaller than that in varus knees at all three levels (P < 0.01). The mean LCLA in valgus knees was significantly smaller than that in varus knees at the 10 mm proximal (P = 0.013) and reference levels (P = 0.015). No significant difference was observed between valgus and varus knees at the 10 mm distal level. The mean MCH and LCH in valgus knees were significantly lower than those in varus knees at all three levels (P < 0.01) (Table 4 ). Table 4 Comparison between valgus and varus knees in MCLA, LCLA, MCH, and LCH. Valgus Varus P value MCLA (°) 10 mm proximal 69.2 ± 8.5 75.2 ± 6.7 < 0.01 Reference 68.1 ± 8.5 74.8 ± 5.9 < 0.01 10 mm distal 67.0 ± 7.5 71.8 ± 5.3 < 0.01 LCLA (°) 10 mm proximal 79.1 ± 4.8 81.3 ± 4.1 0.013 Reference 78.4 ± 4.3 80.4 ± 4.7 0.015 10 mm distal 79.5 ± 4.4 81.2 ± 4.5 n.s MCH (mm) 10 mm proximal 20.4 ± 3.5 23.7 ± 3.1 < 0.01 Reference 21.3 ± 3.5 24.7 ± 3.1 < 0.01 10 mm distal 23.5 ± 4.0 27.1 ± 3.4 < 0.01 LCH (mm) 10 mm proximal 26.4 ± 3.6 29.4 ± 3.3 < 0.01 Reference 27.3 ± 3.8 30.3 ± 3.3 < 0.01 10 mm distal 29.5 ± 4.5 32.7 ± 3.5 < 0.01 Values are the mean ± standard deviation. Discussion The primary discovery of this study was the shorter and more inclined nature of the medial cortex compared to the lateral cortex of the distal femur. In addition, the distal femoral cortex of valgus knees was smaller and more inclined than that of varus knees on both the medial and lateral sides. In biplanar DFO, especially in patients with valgus, care must be taken when creating the anterior flange. Several previous reports have described surgical techniques for ascending osteotomy of the anterior flange in biplanar DFO, focusing on the angle against transverse osteotomy and flange length. Previous reports have described initiating the ascending cut at the anterior one-fourth of the femur, followed by creating the anterior flange at an angle of 90–95° relative to the transverse osteotomy, with a length of 3–4 cm in the biplanar MCWDFO 5,8,20,25–28 . Similarly, Woude et al. 21 reported that the ascending osteotomy was initiated at the anterior one-fourth of the distal femur and directed proximally in biplanar LCWDFO. Although these reports described the angle against transverse osteotomy, previous studies did not specifically address the angle against the femoral cortex in the axial plane. In this study, we revealed significant differences between the medial and lateral cortex shapes and valgus and varus knees. In the reference slice where the transverse osteotomy was initiated, the mean MCLA of the valgus knee was 68.1°, whereas that of the varus knee was 80.4°. Regarding cortex height, the mean MCH of valgus knees was 21.3 mm, whereas that of varus knees was 30.3 mm. Considering that the width of the shaft of the DFO plates was approximately 20 mm, less than 10 mm was left for the anterior flange in the biplanar medial DFO. Thus, it is necessary to carefully determine the anterior flange thickness during biplanar medial DFO, particularly in patients with small femurs. Although the appropriate flange thickness and angle must be determined, our results may provide valuable insights into determining the cutting angle and starting point for creating the surgeon’s preferred anterior flange. In this study, we observed a flattened shape in the medial cortex of some patients with valgus knees. Differentiating the turning point between the anterior and medial cortices was challenging in these cases. Therefore, surgeons may make errors when choosing the appropriate height and angle for creating the anterior flange during biplanar MCWDFO. Given that vertical cuts are easier than oblique cuts into the cortex, surgeons tend to cut vertically into the cortex when creating the anterior flange (Fig. 4 ). In such cases, the width of the opposite hinge is small, particularly in the MCWDFO. Therefore, careful attention is required when creating an anterior flange, particularly for biplanar MCWDFO. Fujita et al. 29 reported hinge fractures in 57% of patients after biplanar MCWDFO. Matsushita et al. 22 reported a significantly higher incidence of hinge fractures after biplanar MCWDFO than after LCWDFO via DLO (70% vs. 30%). These reports showed a high incidence of hinge fractures in biplanar MCWDFO. The results of the present study suggest that an inappropriate anterior flange may be partially associated with a high incidence of hinge fractures in MCWDFO. Kim et al. 30 reported a 42% incidence of hinge fractures in patients undergoing various types of DFO, including MCWDFO, LCWDFO, medial opening wedge DFO, and lateral opening wedge DFO. Notably, they observed that the anterior flange thickness was not associated with hinge fractures. However, their measurement of anterior flange thickness focused solely on the osteotomy side in the sagittal view, excluding the opposite hinge side. Further studies are required to determine the involvement of the anterior flange in hinge fractures. Limitations This study has some limitations. First, the number of patients, particularly those who underwent osteotomy, was small; however, the study confirmed sufficient power to detect differences between the groups. Additionally, the current study focused solely on the differences between varus and valgus knees, neglecting surgical indications, and the number of patients unlikely to affect the results. Second, patients with valgus knees were significantly older and shorter than those with varus knees. This significant difference might be influenced by variations in generation and body size. However, our study suggests that surgeons should be careful when performing biplanar DFO in older patients with valgus knees. Third, the study did not examine the influence of the anterior flange on the incidence of hinge fractures in biplanar DFO. Therefore, future research should focus on determining suitable cutting angles and anterior flange thicknesses. Despite these limitations, this study provides useful information regarding the anatomical characteristics of the distal femur in biplanar DFO. Conclusion At the osteotomy level, the medial cortical angle and height were shorter and more inclined than those of the lateral cortex in the distal femurs, especially in patients with valgus knees. These results suggest that careful attention is required when creating an anterior flange during biplanar DFO, particularly in patients with valgus knees. Declarations Additional Information This manuscript has not been published or presented elsewhere in part or in entirety and is not under consideration by another journal. Written informed consent was obtained from all participants in the present study. The present study was approved by the Institutional Review Board of Kobe University. There are no conflicts of interest to declare. Author Contribution All authors (1) conceived and designed the study or acquired, analyzed, and interpreted the data; (2) drafted the article or made significant revisions regarding important intellectual content; (3) gave final approval of the version to be submitted; and (4) ensured that any questions regarding the accuracy or completeness of any part of the study were properly resolved. The authors agree to be accountable for all aspects of the study and made significant contributions to the literature. The specific contributions of the authors are as follows: (1) Conception and design: Shohei Sano (S.S.), Takehiko Matsushita (T.M.1), Naosuke Nagata (N.N.), Takeo Tokura (T.T.), Koji Nukuto (K.N.1), Yuta Nakanishi (Y.N.), Kyohei Nishida (K.N.2), Kanto Nagai (K.N.3), Noriyuki Kanzaki (N.K.), Yuichi Hoshino (Y.H.), Tomoyuki Matsumoto (T.M.2), and Ryosuke Kuroda (R.K.)(2) Acquisition, analysis, and interpretation of data: S.S., T.M.1, N.N., T.T., K.N.1, and T.M.2. (3) Drafting the article: S.S. and T.M.1. (4) Critical manuscript revision for important intellectual content: S.S., T.M.1, Y.N., Y.H., T.M.2 and R.K. (5) Final approval of the version to be published: S.S., T.M.1, N.N., T.T., K.N.1, Y.N., K.N.2, K.N.3, N. K., Y.H., T.M.2 and R.K. (6) Agreement to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved: T.M.1, Y.H., T.M.2 and R.K. 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Factors affecting the disparity between preoperative planning and postoperative correction status in distal femoral osteotomy. Knee 27, 1608–1617 (2020). (DOI 10.1016/j.knee.2020.08.020 ) (Pubmed:33010780) Additional Declarations No competing interests reported. Supplementary Files Supplementaltable.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 26 Mar, 2024 Reviews received at journal 25 Mar, 2024 Reviews received at journal 10 Mar, 2024 Reviewers agreed at journal 06 Mar, 2024 Reviews received at journal 16 Feb, 2024 Reviewers agreed at journal 15 Feb, 2024 Reviewers invited by journal 15 Feb, 2024 Editor assigned by journal 15 Feb, 2024 Editor invited by journal 15 Feb, 2024 Submission checks completed at journal 15 Feb, 2024 First submitted to journal 06 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3932959","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":273126927,"identity":"7ad9ddb2-7017-4b73-ae4b-7f211c9441b8","order_by":0,"name":"Shohei Sano","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Shohei","middleName":"","lastName":"Sano","suffix":""},{"id":273126928,"identity":"9464044e-a896-4353-8d9e-249d9397b2b5","order_by":1,"name":"Takehiko Matsushita","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYPCCAzz8QFKC4QBDAkyIGbdqZogWyQZStTAYHEDTghPotp8//Jnnzx0Z42uHD95gOGOTx8/AY8Dwo4aB3RyHFrMzyWzSvG3PeMxupyVbMNxIK5Zs4DFg7DnGwGzZgEPLgWQ2Zt6Gw0AtOWYSDB8OJ264/8aAgbeBgRnkVKxazj9mBjrsMI/x7PxvYC37DwBt+YtPy41kBmketsM8BtI5bBIMN4C2AP3CjNeWG4/NJOe2HeaRuJ1mbJFwJq1Y4gBbwWGZYxK4/XI+8fGHN38O2/PPTn5448MxYIg1MG98+KbGJhlXiKGCBCgNdJJEsgFRWpCBHelaRsEoGAWjYJgCAJ2mWsNMZ72+AAAAAElFTkSuQmCC","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Takehiko","middleName":"","lastName":"Matsushita","suffix":""},{"id":273126929,"identity":"ac7d53f5-b90b-4450-bae0-2c46aa487fe5","order_by":2,"name":"Naosuke Nagata","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Naosuke","middleName":"","lastName":"Nagata","suffix":""},{"id":273126930,"identity":"24ff7ea8-c20b-4c27-8f3a-90b6c6a8bbe0","order_by":3,"name":"Takeo Tokura","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Takeo","middleName":"","lastName":"Tokura","suffix":""},{"id":273126931,"identity":"85df2639-7159-46b8-afd0-6b840a78c418","order_by":4,"name":"Koji Nukuto","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Nukuto","suffix":""},{"id":273126932,"identity":"24724e5d-9ace-4790-9231-27194e890f15","order_by":5,"name":"Yuta Nakanishi","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuta","middleName":"","lastName":"Nakanishi","suffix":""},{"id":273126933,"identity":"03a0a61e-e572-4ceb-b0e8-2fdff0f81004","order_by":6,"name":"Kyohei Nishida","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kyohei","middleName":"","lastName":"Nishida","suffix":""},{"id":273126934,"identity":"f42ee0f0-e7d5-46ca-9789-3ff70b01c758","order_by":7,"name":"Kanto Nagai","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kanto","middleName":"","lastName":"Nagai","suffix":""},{"id":273126935,"identity":"49f66e5b-c5f9-46e2-aa76-9166427e5e08","order_by":8,"name":"Noriyuki Kanzaki","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Noriyuki","middleName":"","lastName":"Kanzaki","suffix":""},{"id":273126936,"identity":"f8a8bdd2-6f99-4014-9fc0-52f9b9ce3e6a","order_by":9,"name":"Yuichi Hoshino","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuichi","middleName":"","lastName":"Hoshino","suffix":""},{"id":273126937,"identity":"e7c128a7-9308-4b2c-bffc-42e35623f6c8","order_by":10,"name":"Tomoyuki Matsumoto","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tomoyuki","middleName":"","lastName":"Matsumoto","suffix":""},{"id":273126938,"identity":"893abaed-6507-46c6-866a-234fa16c7741","order_by":11,"name":"Ryosuke Kuroda","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ryosuke","middleName":"","lastName":"Kuroda","suffix":""}],"badges":[],"createdAt":"2024-02-06 05:59:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3932959/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3932959/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51330279,"identity":"52e960ad-6398-4951-9249-69d2f744c1e1","added_by":"auto","created_at":"2024-02-19 17:47:19","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":456010,"visible":true,"origin":"","legend":"\u003cp\u003eA case of biplanar medial closing wedge osteotomy (MCWDFO). The patient is a 36-year-old female. (Left) Lateral and medial view images of three-dimensional computed tomography, 2 weeks after surgery. (Right) Axial images correspond to the level indicated by the broken lines.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3932959/v1/5d797d63608b215109f09cc1.jpeg"},{"id":51330278,"identity":"32813e5b-1433-42f8-9d7f-2813f0a4e000","added_by":"auto","created_at":"2024-02-19 17:47:16","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":438157,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMeasurement of the femoral cortex angle. An image of the axial view of the right knee at the reference level.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) A straight line was drawn along the posterior margin of the femur (Line 1).\u003c/p\u003e\n\u003cp\u003e2) A line was drawn parallel to line 1 through the front tip of the femur (Line 2).\u003c/p\u003e\n\u003cp\u003e3) A line was drawn between the middle of lines 1 and 2 (Line 3) to determine the intersection of the inside and outside (A, B).\u003c/p\u003e\n\u003cp\u003e4) Tangential lines from A to the medial cortex (Line 4) and from B to the lateral cortex (Line 5) were drawn.\u003c/p\u003e\n\u003cp\u003e5) The angle between Line 1 and Line 4 is defined as the medial cortex line angle (MCLA), whereas the angle between Line 1 and Line 5 is referred to as the lateral cortex line angle (LCLA).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3932959/v1/8131c091a5aedd50da0e1e51.jpeg"},{"id":51330172,"identity":"f047347e-d158-4090-b933-230cf436b116","added_by":"auto","created_at":"2024-02-19 17:46:54","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":306901,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMeasurement of the femoral cortex height\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) Tangential lines to the inside of the posterior cortex (Line 6) and the anterior cortex (Line 7) were drawn.\u003c/p\u003e\n\u003cp\u003e2) A vertical line was drawn from Lines 6 to 7, with the inner intersection as Point M and the outer intersection as Point L.\u003c/p\u003e\n\u003cp\u003e3) The vertical distance between Line 6 and Point M was defined as the medial cortex height (MCH), and that between Lines 7 and Point L was defined as the lateral cortex height (LCH).\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3932959/v1/b0f17a166c561001a7cdcb6d.jpeg"},{"id":51330174,"identity":"d2def585-331f-4956-933c-794a60ca3d45","added_by":"auto","created_at":"2024-02-19 17:46:54","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":142317,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTypical femur shape in valgus and varus knee\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA: 43-year-old female with a valgus knee (Left knee).\u003c/p\u003e\n\u003cp\u003eB: 58-year-old male with a varus knee (Left knee).\u003c/p\u003e\n\u003cp\u003e※ The left side is the medial side, and the right side is the lateral side. The axial slice was 65 mm proximal to the knee joint line.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3932959/v1/dcd3a1bd1e801bc05b895e37.jpeg"},{"id":51330325,"identity":"86f72c9b-3ae0-4d73-a913-083861702726","added_by":"auto","created_at":"2024-02-19 17:47:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1039415,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3932959/v1/7fc6eeb1-261e-49cf-9a5d-012683a7a746.pdf"},{"id":51330280,"identity":"dba88f01-3abd-49a5-9acc-3d45d943e493","added_by":"auto","created_at":"2024-02-19 17:47:20","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":234814,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaltable.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3932959/v1/c6c8c8a80efc2fb653f1f326.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Morphological Analysis of the Distal Femur as a Surgical Reference in Biplane Distal Femoral Osteotomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDistal femoral osteotomy (DFO) is a surgical procedure used alone or in combination with proximal tibial osteotomy to treat patients with lower-limb malalignment\u003csup\u003e1\u0026ndash;9\u003c/sup\u003e. Medial closing wedge DFO (MCWDFO) is performed in patients with valgus knee osteoarthritis (OA)\u003csup\u003e3,5,8,10\u0026ndash;13\u003c/sup\u003e, whereas lateral closing wedge DFO (LCWDFO) is performed in conjunction with high tibial osteotomy (HTO) to treat severe varus knee OA, creating a double-level osteotomy (DLO)\u003csup\u003e14\u0026ndash;19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRegarding surgical techniques, biplanar osteotomy has gained popularity in HTO and DFO. Its widespread adoption is attributed to its advantages, such as a large contact area and better stability against axial load\u003csup\u003e20,21\u003c/sup\u003e. In addition, the biplanar osteotomy technique offers the advantage of effectively reducing fragments in hinge fractures. The anterior flange can be used to control fragment rotation during the procedure. Although the biplanar osteotomy technique offers such advantages, it is more technically challenging than single-plane osteotomy. In biplanar DFO, careful attention is required to determine the osteotomy angle and thickness when creating the anterior flange. A higher incidence of hinge fractures occurs after MCWDFO than after LCWDFO via DLO\u003csup\u003e22\u003c/sup\u003e. Upon reviewing our previous cases of DFO, we observed a higher occurrence of hinge fractures in patients who underwent MCWDFO than in those who underwent LCWDFO due to an excessively thick anterior flange. This resulted in a substantial decrease in the width of the opposite hinge compared to those who underwent LCWDFO (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This difference appears to be attributable to anatomical differences between the medial and lateral cortices. Familiarity with the anatomical shape of the distal femur is crucial for accurately forming the anterior flange in biplanar DFO. However, details of the distal femoral bony morphology for distal femoral osteotomy have not been reported. We hypothesized that the distal femoral cortex is shorter and more inclined on the medial side than on the lateral side and that the distal femoral cortex of valgus knees is smaller and more inclined than that of varus knees. This study aimed to examine the morphological characteristics of the bony cortex of the distal aspect of the femur by comparing valgus and varus knees.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eIn total, 100 knees of 97 patients who underwent DFO or total knee arthroplasty (TKA) between February 2018 and March 2022 at our institution were included in this study. To analyze valgus knee OA, 50 knees of 49 patients who underwent TKA or DFO for this condition were selected. To analyze varus knees, 50 knees from 48 patients who underwent HTO or DLO for this condition were selected (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This retrospective study was approved by the Institutional Review Board of our institution, and written informed consent was obtained from all patients before their enrollment.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographic, surgical, and radiographic data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValgus (n = 50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVarus (n = 50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient demographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.0\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (male/female)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e16/34\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e30/20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e157.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e163.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight (kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e61.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e70.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e26.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiographic evaluation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative FTA (\u0026deg;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e165.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e180.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative %MA (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e88.9\u0026thinsp;\u0026plusmn;\u0026thinsp;30.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEvaluation of surgical procedures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTKA/Osteotomy (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e35/15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0/50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMono-plane/Bi-plane (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e6/9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e9/4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en.s\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003en\u003c/em\u003e, number of knees; \u003cem\u003eFTA.\u003c/em\u003e femorotibial angle; \u003cem\u003eMA\u003c/em\u003e, mechanical axis; \u003cem\u003en.s\u003c/em\u003e, not significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between MCLA and LCLA in valgus and varus knees.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMCLA (\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLCLA (\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValgus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 mm proximal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e68.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e78.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e67.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e79.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVarus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm proximal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e81.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e74.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e80.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e71.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e81.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eThe inclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) patients who underwent TKA or knee osteotomy (DFO, HTO, DLO) and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) those who underwent plain computed tomography prior to surgery. The exclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) severe post-traumatic deformity, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) post-infectious knee arthritis, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) rheumatoid arthritis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical indication\u003c/h2\u003e \u003cp\u003eThe indications for MCWDFO were lateral compartment OA with cartilage damage, patellar dislocation with a mechanical lateral distal femoral angle (mLDFA)\u0026thinsp;\u0026le;\u0026thinsp;85\u0026deg;, and % mechanical axis (MA)\u0026thinsp;\u0026ge;\u0026thinsp;55%; HTO was recommended for patients with medial knee OA. DLO was performed if a medial opening gap\u0026thinsp;\u0026gt;\u0026thinsp;20 mm was required or if the mechanical proximal angle exceeded 95\u0026deg; after correction to achieve the target alignment in preoperative planning. DLO was also performed in patients with an mLDFA\u0026thinsp;\u0026ge;\u0026thinsp;90\u0026deg;. Indications for TKA for valgus knee OA are low activity levels and severe knee deformities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cp\u003eMeasurement level\u003c/p\u003e \u003cp\u003eAxial CT images were used for these measurements. An axial slice 65 mm proximal to the knee joint line, which corresponds to 40 mm proximal to the medial or lateral epicondyle, served as the primary reference level. The slice position was selected based on the average starting level of the transverse osteotomy in patients who underwent DFO at our hospital. Subsequently, the cortex angle and height were measured on the reference slice, along with slices positioned 10 mm proximal and 10 mm distal to the reference slice.\u003c/p\u003e \u003cp\u003eAngle\u003c/p\u003e \u003cp\u003eFirst, a straight line was drawn along the posterior margin of the femur (Line 1). Second, we drew a line parallel to Line 1 through the front tip of the femur (Line 2). Third, we drew a line between the middle of Lines 1 and 2 (Line 3) and determined the intersection of the inside and outside (A, B). Fourth, tangential lines were drawn through Point A to the medial cortex (Line 4) and through Point B to the lateral cortex (Line 5). Fifth, the angle between Line 1 and Line 4 was defined as the medial cortex line angle (MCLA), and the angle between Line 1 and Line 5 was termed the lateral cortex line angle (LCLA) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHeight\u003c/p\u003e \u003cp\u003eFirst, tangential lines were drawn to the inside of the posterior cortex (Line 6) and anterior cortex (Line 7). Second, a vertical line was drawn from Lines 6 to 7, with the inner intersection point as Point M and the outer intersection point as Point L. Third, the vertical distance between Line 6 and Point M was defined as the medial cortex height (MCH), and that between Line 7 and Point L was defined as the lateral cortex height (LCH) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eThe number of samples was determined based on a priori sample size calculations. A priori power analysis using G*Power (Heinrich Heine Universitȁt Dȕsseldorf, Germany) indicated a minimum of 47 samples for each group to detect a difference between the two groups with an alpha level of 0.05, a beta of 80%, and an effect size of 0.58. Considering the error margin, the sample size was set to 50 for each group. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (R Foundation for Statistical Computing, Vienna, Austria)\u003csup\u003e23\u003c/sup\u003e. The normality test was the Shapiro\u0026ndash;Wilk test. Owing to the normality of the data, the Mann-Whitney U test or Student t-test was used to compare continuous values between the two groups. Fisher\u0026rsquo;s exact test was used to compare categorical values. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The inter-class correlation coefficient (ICC) was used to assess inter-rater and intra-rater reliability for MCLA, LCLA, MCH, and LCH. ICC\u0026thinsp;\u0026lt;\u0026thinsp;0.50 was considered poor reliability, 0.50\u0026thinsp;\u0026le;\u0026thinsp;ICC\u0026thinsp;\u0026lt;\u0026thinsp;0.75 was considered moderate reliability, 0.75\u0026thinsp;\u0026le;\u0026thinsp;ICC\u0026thinsp;\u0026lt;\u0026thinsp;0.90 was considered good reliability, and ICC\u0026thinsp;\u0026ge;\u0026thinsp;0.90 was considered excellent reliability\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eValidation of measurement methods for distal femur shape\u003c/h2\u003e \u003cp\u003eThe ICC values for each angle and height (MCLA, LCLA, MHC, and LCH) are summarized in Supplemental Table\u0026nbsp;1. Overall, good-to-excellent intra-rater reliability was obtained for MCLA, LCLA, MHC, and LCH. Similarly, good-to-excellent ICC values for inter-rater agreement were obtained (Supplemental Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eComparison of the cortex angle between the medial and lateral side of the distal femur in valgus and varus knees\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mean MCLA was significantly smaller than the LCLA in both valgus and varus knees at all three levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Table. 2).\u003c/p\u003e \u003cp\u003e \u003cb\u003eComparison of cortex height between the medial and lateral side of the distal femur in valgus and varus knees\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mean LCH was significantly higher than the mean MCH in the valgus and varus knees at all three levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between MCH and LCH in valgus and varus knees.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMCH (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLCH (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValgus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 mm proximal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e21.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVarus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm proximal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e30.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e27.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e32.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eComparison of cortex angle and height between valgus and varus knees\u003c/h2\u003e \u003cp\u003eThe mean MCLA in valgus knees was significantly smaller than that in varus knees at all three levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The mean LCLA in valgus knees was significantly smaller than that in varus knees at the 10 mm proximal (P\u0026thinsp;=\u0026thinsp;0.013) and reference levels (P\u0026thinsp;=\u0026thinsp;0.015). No significant difference was observed between valgus and varus knees at the 10 mm distal level. The mean MCH and LCH in valgus knees were significantly lower than those in varus knees at all three levels (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between valgus and varus knees in MCLA, LCLA, MCH, and LCH.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValgus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVarus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCLA (\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 mm proximal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e68.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e74.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e67.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e71.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLCLA (\u0026deg;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm proximal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e79.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e81.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e78.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e80.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e79.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e81.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en.s\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMCH (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm proximal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e20.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e21.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e27.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLCH (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm proximal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e30.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 mm distal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e32.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary discovery of this study was the shorter and more inclined nature of the medial cortex compared to the lateral cortex of the distal femur. In addition, the distal femoral cortex of valgus knees was smaller and more inclined than that of varus knees on both the medial and lateral sides. In biplanar DFO, especially in patients with valgus, care must be taken when creating the anterior flange.\u003c/p\u003e \u003cp\u003eSeveral previous reports have described surgical techniques for ascending osteotomy of the anterior flange in biplanar DFO, focusing on the angle against transverse osteotomy and flange length. Previous reports have described initiating the ascending cut at the anterior one-fourth of the femur, followed by creating the anterior flange at an angle of 90\u0026ndash;95\u0026deg; relative to the transverse osteotomy, with a length of 3\u0026ndash;4 cm in the biplanar MCWDFO\u003csup\u003e5,8,20,25\u0026ndash;28\u003c/sup\u003e. Similarly, Woude et al.\u003csup\u003e21\u003c/sup\u003e reported that the ascending osteotomy was initiated at the anterior one-fourth of the distal femur and directed proximally in biplanar LCWDFO. Although these reports described the angle against transverse osteotomy, previous studies did not specifically address the angle against the femoral cortex in the axial plane. In this study, we revealed significant differences between the medial and lateral cortex shapes and valgus and varus knees. In the reference slice where the transverse osteotomy was initiated, the mean MCLA of the valgus knee was 68.1\u0026deg;, whereas that of the varus knee was 80.4\u0026deg;. Regarding cortex height, the mean MCH of valgus knees was 21.3 mm, whereas that of varus knees was 30.3 mm. Considering that the width of the shaft of the DFO plates was approximately 20 mm, less than 10 mm was left for the anterior flange in the biplanar medial DFO. Thus, it is necessary to carefully determine the anterior flange thickness during biplanar medial DFO, particularly in patients with small femurs. Although the appropriate flange thickness and angle must be determined, our results may provide valuable insights into determining the cutting angle and starting point for creating the surgeon\u0026rsquo;s preferred anterior flange.\u003c/p\u003e \u003cp\u003eIn this study, we observed a flattened shape in the medial cortex of some patients with valgus knees. Differentiating the turning point between the anterior and medial cortices was challenging in these cases. Therefore, surgeons may make errors when choosing the appropriate height and angle for creating the anterior flange during biplanar MCWDFO. Given that vertical cuts are easier than oblique cuts into the cortex, surgeons tend to cut vertically into the cortex when creating the anterior flange (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In such cases, the width of the opposite hinge is small, particularly in the MCWDFO. Therefore, careful attention is required when creating an anterior flange, particularly for biplanar MCWDFO. Fujita et al.\u003csup\u003e29\u003c/sup\u003e reported hinge fractures in 57% of patients after biplanar MCWDFO. Matsushita et al.\u003csup\u003e22\u003c/sup\u003e reported a significantly higher incidence of hinge fractures after biplanar MCWDFO than after LCWDFO via DLO (70% vs. 30%). These reports showed a high incidence of hinge fractures in biplanar MCWDFO. The results of the present study suggest that an inappropriate anterior flange may be partially associated with a high incidence of hinge fractures in MCWDFO. Kim et al.\u003csup\u003e30\u003c/sup\u003e reported a 42% incidence of hinge fractures in patients undergoing various types of DFO, including MCWDFO, LCWDFO, medial opening wedge DFO, and lateral opening wedge DFO. Notably, they observed that the anterior flange thickness was not associated with hinge fractures. However, their measurement of anterior flange thickness focused solely on the osteotomy side in the sagittal view, excluding the opposite hinge side. Further studies are required to determine the involvement of the anterior flange in hinge fractures.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has some limitations. First, the number of patients, particularly those who underwent osteotomy, was small; however, the study confirmed sufficient power to detect differences between the groups. Additionally, the current study focused solely on the differences between varus and valgus knees, neglecting surgical indications, and the number of patients unlikely to affect the results. Second, patients with valgus knees were significantly older and shorter than those with varus knees. This significant difference might be influenced by variations in generation and body size. However, our study suggests that surgeons should be careful when performing biplanar DFO in older patients with valgus knees. Third, the study did not examine the influence of the anterior flange on the incidence of hinge fractures in biplanar DFO. Therefore, future research should focus on determining suitable cutting angles and anterior flange thicknesses. Despite these limitations, this study provides useful information regarding the anatomical characteristics of the distal femur in biplanar DFO.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAt the osteotomy level, the medial cortical angle and height were shorter and more inclined than those of the lateral cortex in the distal femurs, especially in patients with valgus knees. These results suggest that careful attention is required when creating an anterior flange during biplanar DFO, particularly in patients with valgus knees.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eAdditional Information\u003c/h2\u003e \u003cp\u003eThis manuscript has not been published or presented elsewhere in part or in entirety and is not under consideration by another journal. Written informed consent was obtained from all participants in the present study. The present study was approved by the Institutional Review Board of Kobe University. There are no conflicts of interest to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors (1) conceived and designed the study or acquired, analyzed, and interpreted the data; (2) drafted the article or made significant revisions regarding important intellectual content; (3) gave final approval of the version to be submitted; and (4) ensured that any questions regarding the accuracy or completeness of any part of the study were properly resolved. The authors agree to be accountable for all aspects of the study and made significant contributions to the literature. The specific contributions of the authors are as follows: (1) Conception and design: Shohei Sano (S.S.), Takehiko Matsushita (T.M.1), Naosuke Nagata (N.N.), Takeo Tokura (T.T.), Koji Nukuto (K.N.1), Yuta Nakanishi (Y.N.), Kyohei Nishida (K.N.2), Kanto Nagai (K.N.3), Noriyuki Kanzaki (N.K.), Yuichi Hoshino (Y.H.), Tomoyuki Matsumoto (T.M.2), and Ryosuke Kuroda (R.K.)(2) Acquisition, analysis, and interpretation of data: S.S., T.M.1, N.N., T.T., K.N.1, and T.M.2. (3) Drafting the article: S.S. and T.M.1. (4) Critical manuscript revision for important intellectual content: S.S., T.M.1, Y.N., Y.H., T.M.2 and R.K. (5) Final approval of the version to be published: S.S., T.M.1, N.N., T.T., K.N.1, Y.N., K.N.2, K.N.3, N. K., Y.H., T.M.2 and R.K. (6) Agreement to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved: T.M.1, Y.H., T.M.2 and R.K.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eWe would like to thank Editage (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"10.1016/j.arth.2007.01.026\" target=\"_blank\"\u003ewww.editage.jp\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.editage.jp\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) for the English language editing.\u003c/p\u003e\u003ch2\u003eData availability statement\u003c/h2\u003e \u003cp\u003eData supporting the findings of this study are available upon request from the corresponding authors. The data are not publicly available due to privacy concerns.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBackstein, D., Morag, G., Hanna, S., Safir, O. \u0026amp; Gross, A. Long-term follow-up of distal femoral varus osteotomy of the knee. J. Arthroplasty 22, 2\u0026ndash;6 (2007). (DOI \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.arth.2007.01.026\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2007.01.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (Pubmed:17570268)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosso, F. \u0026amp; Margheritini, F. Distal femoral osteotomy. Curr. Rev. Musculoskelet. Med. 7, 302\u0026ndash;311 (2014). 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Correction of severe knees valgus deformities in a patient with renal osteodystrophy. JAAOS Global Research \u0026amp; Reviews 6, (2022). (DOI \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5435/JAAOSGlobal-D-22-00113\u003c/span\u003e\u003cspan address=\"10.5435/JAAOSGlobal-D-22-00113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (Pubmed:36129966)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrasso, F. \u003cem\u003eet al.\u003c/em\u003e Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: A prospective analysis of a cohort of twenty-two continuous patients. Int. Orthop. 46, 473\u0026ndash;479 (2022). 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Return to sports after valgus osteotomy of the knee joint in patients with medial unicompartmental osteoarthritis. Int. Orthop. 38, 2109\u0026ndash;2114 (2014). (DOI \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00264-014-2435-6\u003c/span\u003e\u003cspan address=\"10.1007/s00264-014-2435-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (Pubmed:24993653)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuethman, N. C., Bernard, C. D., Camp, C. L., Krych, A. J. \u0026amp; Stuart, M. J. Medial closing wedge distal femoral osteotomy. Clin. Sports Med. 38, 361\u0026ndash;373 (2019). 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(DOI \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.knee.2020.08.020\u003c/span\u003e\u003cspan address=\"10.1016/j.knee.2020.08.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (Pubmed:33010780)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3932959/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3932959/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDistal femoral osteotomy (DFO) is performed alone or with high tibial osteotomy (HTO) for patients with osteoarthritis and distal femur deformities. DFO is technically demanding, particularly when creating an anterior flange. Herein, we examined the morphological characteristics of the distal femur based on the cortical shape as a surgical reference for biplanar DFO. Computed tomography images of 50 valgus and 50 varus knees of patients who underwent biplanar DFO or total knee arthroplasty were analyzed. Axial slices at the initial level of the transverse osteotomy in the DFO and slices 10 mm proximal and 10 mm distal to that level were selected. The medial and lateral cortical angles and heights (MCLA, LCLA, MCH, and LCH) were measured on axial slices. Statistical comparisons were performed between the medial and lateral cortices and valgus and varus knees. MCLA and MCH were significantly smaller and lower, respectively, than LCLA and LCH (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The MCLA and MCH of varus knees were significantly smaller and lower, respectively, than those of valgus knees (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Surgeons should carefully observe morphological differences in the distal femur cortex, distinguishing between medial and lateral knees and varus and valgus knees during the creation of the anterior flange in the DFO.\u003c/p\u003e","manuscriptTitle":"Morphological Analysis of the Distal Femur as a Surgical Reference in Biplane Distal Femoral Osteotomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-19 17:46:41","doi":"10.21203/rs.3.rs-3932959/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-26T05:48:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-25T13:08:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-10T09:48:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7f25ab2c-18a3-4521-93d5-796aa944178e","date":"2024-03-06T07:20:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-16T15:54:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e2c3490c-5bec-4e4a-97ea-8aaeee2f3445","date":"2024-02-15T15:11:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-15T15:04:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-15T15:00:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-15T08:32:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-15T08:29:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-02-06T05:50:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"22bc0bf9-f581-4094-9de5-fa87c0750cb8","owner":[],"postedDate":"February 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":28792200,"name":"Health sciences/Anatomy/Musculoskeletal system"},{"id":28792201,"name":"Health sciences/Health care/Medical imaging/Bone imaging"}],"tags":[],"updatedAt":"2024-05-23T07:46:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-19 17:46:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3932959","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3932959","identity":"rs-3932959","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}