Biomechanical studies in distal femoral osteotomy: A literature review

• This review synthesizes 45 biomechanical studies on distal femoral osteotomy. • Hinge position strongly influences fracture risk, with condylar placement being most favorable. • Bi-planar osteotomy cuts increase cortical contact and promote healing. • Literature reveals major gaps on hinge fracture modelling, healing biomechanics and rehabilitation effects. Distal femoral osteotomy (DFO) is a surgical intervention primarily indicated for the correction of valgus malalignment of the knee associated with lateral compartment osteoarthritis. Despite its increasing use, the biomechanical principles underlying this procedure remain insufficiently synthesized. This review aims to synthesize experimental, numerical and observational studies investigating the biomechanics of DFO, identify key determinants of surgery outcomes and highlight current limitations and future research directions. A systematic search of PubMed and Web of Science databases was conducted for studies published between 2010 and 2025 using combined keywords related to femoral osteotomy. Eligible studies included original works providing direct biomechanical data or analyses of DFO. Forty-five studies met the inclusion criteria, including 30 primary research articles with direct biomechanical investigations and 15 additional observational studies presenting relevant biomechanical implications. Overall, these studies revolved around the following topics: hinge fracture, correction stability and correction outcome. Hinge position was the primary factor influencing fracture risk, with condylar hinge placement reducing fracture incidence. Bi-planar cuts improved cortical contact and promoted faster bone healing. Angled blade plates provided the highest stiffness, while locking plates achieved comparable stability when supported by hinge screws or grafts. Future research should focus on defining the optimal correction angle, developing hinge fracture models, assessing the biomechanics of postoperative recovery and evaluating the influence of gap fillers.