Influence of varus-producing distal femur osteotomy correction and hinge width in relation to hinge fractures: Biomechanical study on porcine femora

Background: Hinge fractures in varus-producing distal femoral osteotomies (DFOs) lead to decreased axial and torsional stability. The purpose of this study was to assess (1) which hinge width has a high risk of hinge fracture in DFO for lateral opening wedge (LOW) and medial closing wedge (MCW) osteotomies, (2) which osteotomies allow for greater correction before risking a fracture, (3) whether patient-specific instrumentation (PSI) allows accurate hinge width planning. Methods: Thirty porcine femoral bones were divided into two groups: LOW, MCW with hinge widths of 5 mm, 7.5 mm, and 10 mm as subgroups. Osteotomies were performed in a PSI-navigated fashion. A force parallel to the longitudinal bone axis was applied in a uniaxial testing machine until a fracture occurred. Results: The maximum correction was 6.7 ± 1.1° for LOW and 13.4 ± 1.9° for MCW (β0 < 0.001, β1 = 0.002, β2 = 0.02, β3 = 0.005). The relative error of the planned hinge width compared with the actual hinge width was −3.7 ± 12.3% for LOW (P = 0.25) and 12.3 ± 13.1% for MCW (P = 0.003). Conclusions: Increasing the hinge width allows for greater correction in MCW osteotomies. For LOW osteotomies, a smaller hinge width seems to be advantageous because it allows a greater correction without the risk of hinge fracture. With PSI-guided LOW osteotomies, the planned hinge width could be achieved intraoperatively with greater accuracy than with MCW osteotomies. However, the MCW osteotomy appears to be the preferred option when larger corrections are desired because a larger correction angle can be achieved without the risk of intraoperative hinge fracture.