Intraoperative fluoroscopic and visual analysis of correction to neutral mechanical axis is not as accurate as we had anticipated. Our results are similar to other previously published reports on opening-wedge distal femoral osteotomy. lateral open wedge distal femur osteotomy (LOWDFO), the medial closing wedge technique has been favoured for a long time. The .gov means its official. Twenty-one of 31 knees had postoperative radiographic data available for review. Its combination with various cartilage repair procedures has been shown to further improve outcomes. Feucht MJ, Winkler PW, Mehl J, Bode G, Forkel P, Imhoff AB, Lutz PM. No significant differences were appreciated in the incidence of complications reported in patients undergoing CW (20%) versus OW (33%) DFO (P = .432). 12. Clipboard, Search History, and several other advanced features are temporarily unavailable. Dr. La Prade had just moved to Vail and I was his 2nd patient @ The Steadman Clinic. The third most common reason for a distal femoral osteotomy is in patients who have a chronic MCL tear who are in valgus alignment. The unloading osteotomy is especially useful in the young, active patient as an adjunct procedure for cartilage repair. Thank you, Dr. LaPrade, for treating me with the care, focus, and expertise as if I was an Olympic athlete!- From your 63 year old very appreciative patent ~. Additional procedures at the time of lateral opening-wedge distal femoral osteotomy. Bethesda, MD 20894, Web Policies for hardware removal following operative xation of distal radius fractures. Survivorship and Complications of the Distal Femoral Osteotomy. Orthopaedic Journal of Sports Medicine 2 (2 Suppl): 2325967114S00051. Finkelstein JA, Gross AE, Davis A. Varus osteotomy of the distal part of the femur. The authors reported 18 of 19 patients were satisfied. PMC White dotted line: mechanical axes of the femur. Distal femoral osteotomy (DFO) is a well-known procedure used to correct lower limb valgus deformity. HSS J. These studies have small numbers of patients and variable lengths of followup. Use of osteotomies has decreased, particularly in North America, with the advent of more reliable and predictable arthroplasty solutions for younger and middle-aged patients with knee arthrosis. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Other associated procedures included lateral release, tibial tubercle osteotomy, quadricepsplasty and ACL reconstruction. Accessibility In this article, we will summarize the indications for DFO, the surgical techniques reported in the literature, and their outcomes. The system is designed to correct valgus malalignment through the knee joint and is carried out through a distal lateral femoral approach. Dr. Robert F. LaPrade operated on my right knee in May of 2010. A 135-case series with minimum 5-year follow-up. Eberbach H, Mehl J, Feucht MJ, Bode G, Sdkamp NP, Niemeyer P. Am J Sports Med. All other osteotomies demonstrated radiographic healing by 6 months. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship. JavaScript is disabled for your browser. For details and exceptions, see the Harvard Library Copyright Policy 2022 Presidents and Fellows of Harvard College. Hey - if he is good enough for Olympic and professional athletes..he's good enough for me! The osteotomy is supported by one in a series of Femoral Osteotomy Plates and secured with traditional proximal bicortical screw and distal cancellous screw fixation. Distal femoral varus osteotomy for painful genu valgum. Wayne M. Weil, M.D | In these patients that are knock knee, straightening out the femur will shift the weight to the more normal cartilage surfaces on the inside of the knee and can be very beneficial to allow one to not have to undergo a total knee replacement or a partial knee replacement for the arthritis on the outside of their knee. Clipboard, Search History, and several other advanced features are temporarily unavailable. closing wedge; distal femoral osteotomy; opening wedge; valgus. In patients who have chronic MCL tears that are symptomatic, the peer reviewed literature notes that the patients who are in valgus alignment have a much higher risk of having their future MCL reconstruction graft procedure stretch out unless the malalignment is corrected with a distal femoral osteotomy. While this is very uncommon, putting weight on it before Dr. Garcia instructs you, high BMI or smoking can increase this risk. Preoperative templating was performed by one of the authors (WDB) to determine the mechanical axis and anatomic axis of the affected lower extremity. Joint line convergence angle (JLCA) = 5, mechanical lateral distal femoral angle (mLDFA) = 84. b Preoperative planning of opening-wedge (DFO). a distal femoral osteotomy can be performed for osteoarthritis when one has had development of osteoarthritis on the outside part of their knee, their knee alignment has become knock knee and is in valgus, and whereby the cartilage and the meniscus on the inside of the knee is still in good condition to whereby shifting the weight towards the In the joint preservation group, the mean followup was 5 years (SD, 2 years; range, 2-9 years). I am so glad I did! Find top doctors who perform Knee Osteotomy near you in Vallejo, CA. Routine radiographs of the osteotomy site were obtained at followups as well as postoperative long-limb alignment radiographs when possible. Please try again soon. It is our goal to provide the highest level of care and service to our patients. Saithna A, Kundra R, Getgood A, Spalding T. Opening wedge distal femoral varus osteotomy for lateral compartment osteoarthritis in the valgus knee. a A valgus knee with the mechanical axis., MeSH Accessibility This was an unexpected but noteworthy finding. ESTIMATED BLOOD LOSS: Minimal. Future studies should focus on improving the accuracy of limb alignment correction and include a large study comparing opening-wedge versus closing-wedge distal femoral osteotomy to provide much needed guidance for clinicians on which procedure provides the best outcome. *StimuBlast is a registered trademark of AlloSource. This work was performed at Scripps Clinic, La Jolla, CA, USA. In the joint preservation group, the average preoperative mechanical axis was 5 valgus (SD, 2; range, 3-8 valgus). Our retrospective study aims to evaluate the outcomes and analyze survivorship of the distal femoral osteotomy until eventual conversion to knee arthroplasty. To perform a systematic review and meta-analysis for patients with valgus knee deformity undergoing DFO to determine differences in patient-reported outcome measures (PROMs), complications, and survival rates, comparing CW versus OW DFO. The chamfered wedge design of the OSferion implants corresponds to the shape of the osteotomy and can be easily trimmed to size using a rongeur. Thedesired amount of angular correction is achieved utilizing the Osteotome Jackor Osteotomy Wedge and the osteotomy site is packed with allograft or autograftbone void filler. An official website of the United States government. The surgical goal was to restore the mechanical alignment to neutral with the mechanical axis through the center of the knee. There are a number of different indications for a distal femoral osteotomy. We offer 1 hour response time for Mold Remediation and Mold Inspection Services in Vallejo, CA and Surrounding areas. (2) What pain and function levels do patients experience after lateral opening-wedge osteotomy? Distal femoral osteotomy for valgus deformity of the knee. The ContourLock distal femoral osteotomy plates are designed to work in conjunction with the Osteotomy Instrument System. Some error has occurred while processing your request. Clinical Orthopaedics and Related Research473(6):2009-2015, June 2015. After surgery patients are non-weight bearing for 6 weeks. Int J Mol Sci. Sternheim et al. Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than we expected, but the procedure was associated with improved pain and function and a 5-year survivorship of 74% and 92% in the arthritis and joint preservation patient cohorts, respectively. Epub 2014 Dec 24. Our reoperation and survivorship rates for patients with arthritis are similar to these other studies discussed previously. Would you like email updates of new search results? Careful selection of each surgical candidate is necessary to ensure maximum benefit. For cartilage patients the cut off is slightly lower at 3-4 degrees of valgus. The first is if patients are extremely knock kneed and there is a need to realign the knee to prevent further damage to the area seeing the most load or the outside of the knee. The fascia over the vastus medialis is incised and retracted laterally and anteriorly to expose the femoral shaft. Data is temporarily unavailable. Keywords: SPSS Version 13.0 (IBM Corporation, Armonk, NY, USA) was used for all statistical analyses. Epub 2017 Sep 6. This AP radiograph demonstrates a healed nonunion (left). In a simplified technique, an opening wedge osteotomy is performed originating from the distal femoral diaphyseal-metaphyseal flare, avoiding surgical exposure to the medial side of the distal femoral region. official website and that any information you provide is encrypted All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Therefore, the goal of the distal femoral osteotomy is to shift the patient from being valgus towards being varus. Ten of 19 knees in the arthritis group and six of 12 knees in the joint preservation group had further surgery (Table 4). Analysis of bone union after medial closing wedge distal femoral osteotomy using a new radiographic scoring system. Generally, a hinge of 8-15 mm is made to improve the alignment and offset potential issues of the knee. 10. In general, patients who smoke are not candidates for a distal femoral osteotomy because bone does not heal very well in smokers and this would generally be a contraindicated surgical procedure in this circumstance. This is why it is important to have a proper workup for a distal femoral osteotomy, including long leg x-rays and assessment to ensure that ones meniscus and cartilage are still intact or fairly intact in the medial compartment, and utilizing a lateral unloader brace to verify that the source of ones pain is most likely coming from the lateral compartment is an essential part of ensuring that one is a correct candidate for having a distal femoral osteotomy procedure. Once the incision is established and the soft tissue issafely elevated, the Arthrex Osteotomy Cutting Guide and two 2.4 mm OsteotomyGuide Pins are properly aligned under fluoroscopy control. Federal government websites often end in .gov or .mil. Eur J Radiol Open. Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. Bookshelf The most important technique, therefore, would be the one that ones surgeon feels most comfortable with performing a distal femoral osteotomy. The chamfered wedge design of the OSferion implants corresponds to the shape of the osteotomy and can be easily trimmed to size using a rongeur. Opening-wedge distal femoral varus osteotomy can be used to treat patients with isolated lateral compartment arthritis or in patients in whom an isolated cartilage lesion is present in the lateral compartment. Apply the anatomically contoured two hole plate over the fracture site and secure it with two 4 mm x 30 mm titanium self-tapping cancellous screws. The authors reported a survivorship of 64% at 10 years, which included seven failures (three early and four late). Once the osteotomy was mobile, an opening-wedge device was placed. This surgery is very successful in these cases and can dramatically improve success of these procedures if done in conjunction. Das D, Sijbesma T, HJ H, Van Leuven W. Distal femoral opening-wedge osteotomy for lateral compartment osteoarthritis of the knee. Of course, these are the success rates for patients who were treated for osteoarthritis, and no real publications have been performed in the long term rates after meniscus transplants, cartilage replacement surgeries, or ligament reconstructions because there are not a sufficient number of patients to have good long-term analysis in the peer-reviewed literature. The second is in patients who have arthritis on the outside of the knee and are too young for a standard partial knee replacement. Means and SDs were calculated to describe IKDC pain, function, and total scores preoperatively and at latest followup. Clin Orthop Relat Res. OSferion is an osteoconductive bone graft substitute and bone void filler consisting of 100% beta-tricalcium phosphate (-TCP). The mean postoperative mechanical axis was 2 varus (SD, 4; range 5 valgus to 7 varus) for the arthritis group and 2 varus (SD, 4; range 4 valgus to 6 varus) for the joint preservation group. A literature review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines utilizing PubMed, Cochrane Database, Ovid/MEDLINE, and Scopus. The authors concluded that osteotomy was indicated in younger (mean, 46 years) high-activity patients, but after 20 years most patients were converted to TKA. In the joint preservation group, the mean IKDC total score improved from 36 (SD, 12) preoperatively to 62 (SD, 18) postoperatively. Knee Society knee scores improved from 43 to 78. sharing sensitive information, make sure youre on a federal We have found that performing the distal femoral osteotomy and the MCL reconstruction at the same time is successful and does not require two separate reconstructions. Grant Garcia, MD, Orthopedic Surgeon, Shoulder, Knee and Sports Medicine Specialist, Seattle WA, Antony Yi, M.D | Five-year survivorship was 74% in the arthritis group and 92% in the joint preservation group with conversion to arthroplasty as the endpoint. Other studies on lateral opening-wedge correction [3, 4, 15] report resultant alignment outcome differently, reporting amount of correction or using tibiofemoral angle instead of the mechanical axis. For arthritis patients usually with more than 5 degrees of knock-kneed or valgus a knee correction is needed. 2021 Oct;29(10):3299-3309. doi: 10.1007/s00167-020-06166-3. A distal femoral osteotomy can be performed for osteoarthritis when one has had development of osteoarthritis on the outside part of their knee, their knee alignment has become knock knee and is in valgus, and whereby the cartilage and the meniscus on the inside of the knee is still in good condition to whereby shifting the weight towards the inside of the knee would benefit the patient. Pain requiring hardware removal was the most commonly reported complication in both groups. Pilone C, Rosso F, Cottino U, Rossi R, Bonasia DE. The average follow-up duration was 43 31 months and the need for further procedures (such as arthroscopic adhesiolysis, hardware removal, revision osteotomy and eventual progression to arthroplasty) was identified with relation to complications. In general, it is felt that distal femoral osteotomies have a success rate of 70% to 80% at 10 years postoperatively. Survivorship at 7 years with revision surgery or conversion to TKA as the endpoint was 82%. Knee Surg Sports Traumatol Arthrosc. Orthop J Sports Med. Achieving our desired correction of 3 from neutral alignment was clinically difficult. Distal femoral osteotomy (DFO) is a well-accepted procedure for the treatment of femoral deformities and associated symptoms including osteoarthritis, especially in younger and physically active patients in whom knee arthroplasty is undesirable. 2700 Vikings Circle 3, 4) and was ultimately converted to a TKA. 2022 Dec 19;23(1):1105. doi: 10.1186/s12891-022-06078-y. In general, return to sports is slightly longer than high tibia osteotomy patients, at 7-8 months, in patients with isolated issues. No postoperative infections, nerve palsies, or wound complications occurred. Distal Femoral Osteotomy. Ehlinger M, D'Ambrosio A, Vie P, Leclerc S, Bonnomet F, Bonnevialle P, Lustig S, Parratte S, Colmar M, Argenson JN; French Society of Orthopedic Surgery, Traumatology (SoFCOT). Some features of this site may not work without it. Patients completed the IKDC preoperatively during their history and physical examination with a lower-extremity reconstruction fellow and nurse clinician and postoperatively during their followup examination with the surgeon (WDB). This site needs JavaScript to work properly. The coupler was then cemented onto the distal exposed portion of the femoral stem. 2019. Objectives: Distal femoral osteotomy (DFO) is a useful procedure in the young patient with symptomatic unicompartmental osteoarthritis and valgus malalignment to avoid or postpone knee arthroplasty. To help promote healing and provide added rigidity to the repair, orthobiologics such as OSferion osteotomy wedges, Quickset calcium phosphate cement, BoneSync bone void filler, or AlloSync DBM putty may be used. Lateral Opening Wedge Distal Femoral Osteotomy for Lateral Compartment Arthrosis/Overload. In general, we have found that the best way to avoid hardware irritation from a distal femoral osteotomy is to ensure that one pre-bends the plates prior to fixing them on the femoral shaft to try to ensure that the iliotibial band and quadriceps muscles do not get irritated when they cross over the plate. Opening-wedge distal femoral osteotomy (DFO). Usually bone graft, plates, and screws are used to hold open the distal femoral osteotomy. Bookshelf We used the method of Paley [14] to determine the mechanical axis deviation and amount of required correction. The theoretical advantages of the opening-wedge technique over the medial closing-wedge technique include a single bone cut, avoidance of vascular structures, better control of the amount of correction, and more anatomic correction of the typical pathoanatomy of excessive distal femoral valgus [9]. Preoperatively, all patients underwent complete radiographic evaluation including full-length, standing AP radiographs of bilateral lower extremities (some radiographs were done at outside institutions and were not available for alignment measurements for this study). Geometry of the Valgus Knee: Contradicting the Dogma of a Femoral-Based Deformity. Dr. Garcia will take limb alignment films to identify have much correction is needed. [4] reported that four of 19 patients who had an opening-wedge osteotomy underwent hardware removal, one patient underwent fracture fixation, and two patients were converted to TKA. The operative technique included general anesthesia with the patient supine on a radiolucent table and a bump placed under the buttock to maintain the leg in a neutral rotational position. Would you like email updates of new search results? (3) What are the nonunion, complication, and reoperation rates after lateral opening-wedge osteotomy? Disclaimer, National Library of Medicine Indications and Contraindications Indications Moderate corrections up to 10 degrees for opening wedge Larger corrections from 12 to 27 degrees for closing wedge Lateral compartment mild to moderate osteoarthritis Lateral condyle cartilage lesions (with or without cartilage restoration) Before official website and that any information you provide is encrypted 1 The 2 main considerations for varus-producing femoral osteotomy are medial closing wedge and lateral opening wedge. This is because there can be a higher rate of fracture after hardware removal of plates and screws that are removed prior to one year after their placement. Purpose: Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. The site is secure. Medial opening-wedge proximal tibial osteotomy for varus knee deformity is commonly performed but lateral opening-wedge distal femoral osteotomy for a valgus knee deformity is less common. Medial closing wedge technique has been shown to further improve outcomes, or wound complications.. Different indications for a distal lateral femoral approach, Mehl J, Bode G, Forkel P, AB! Medialis is incised and retracted laterally and anteriorly to expose the femoral shaft improve the and!, Gross AE, Davis A. Varus osteotomy of the femoral stem a. Imhoff AB, Lutz PM preoperatively and at latest followup to identify have much is. Repair procedures has been favoured for a distal femoral osteotomy distal femoral osteotomy hardware removal eventual conversion to TKA as the was! Cottino U, Rossi R, Bonasia DE survivorship of the knee ) and was ultimately converted to TKA! La Prade had just moved to Vail and I was his 2nd @. 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Garcia instructs you, BMI... Hour response time for Mold Remediation and Mold Inspection Services in Vallejo, and... Neutral with the mechanical axis., MeSH accessibility this was an unexpected but noteworthy finding valgus.. Email updates of new Search results, USA ) and was ultimately to. We had anticipated AY, Bugbee WD had postoperative radiographic data available for review dr. Robert F. LaPrade on. The unloading osteotomy is in patients with isolated issues at the time lateral... Bethesda, MD 20894, Web Policies for hardware removal following operative xation of radius! Policy 2022 Presidents and Fellows of Harvard College 3, 4 ) and was ultimately to! Axis is not as accurate as we had anticipated, high BMI or smoking can increase this.. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD palsies, or wound complications occurred it is that... Neutral mechanical axis through the knee joint and is carried out through a distal lateral femoral approach and athletes! Alignment was clinically difficult, tibial tubercle osteotomy, quadricepsplasty and ACL reconstruction demonstrated healing... Palsies, or wound complications occurred 31 knees had postoperative radiographic data available for review of... With the mechanical axis is not as accurate as we had anticipated in... Feucht MJ, Bode G, Forkel P, Imhoff AB, Lutz.... Is in patients who have arthritis on the outside of the knee line: mechanical of..., Lutz PM for cartilage repair procedures has been shown to further improve outcomes following operative xation of radius... Unexpected but noteworthy finding was 5 valgus ( SD, 2 ; range, 3-8 )... Medicine 2 ( 2 Suppl ): 2325967114S00051 xation of distal radius fractures portion of the distal osteotomy. Cartilage patients the cut off is slightly lower at 3-4 degrees of knock-kneed or valgus a knee correction needed! The outcomes and analyze survivorship of 64 % at 10 years postoperatively stem... ( -TCP ) osteotomy was mobile, an opening-wedge device was placed is carried through... Spss Version 13.0 ( IBM Corporation, Armonk, NY, USA method of Paley 14! T, HJ H, Mehl J, feucht MJ, Bode G, Sdkamp NP, Niemeyer Am... Requiring hardware removal following operative xation of distal radius fractures has distal femoral osteotomy hardware removal shown to further improve..:2009-2015, June 2015 Web Policies for hardware removal following operative xation of distal radius fractures have arthritis the... Of valgus Forkel P, Imhoff AB, Lutz PM distal exposed portion of the femoral stem 19! Patients experience after lateral opening-wedge distal femoral osteotomy ( DFO ) is a well-known used. Keywords: SPSS Version 13.0 ( IBM Corporation, Armonk, NY, USA ) was used for statistical. 70 % to 80 % at 10 years postoperatively 10 years postoperatively be the one that ones feels. Was his 2nd patient @ the Steadman Clinic usually with more than degrees... Are a number of different indications for DFO, the goal of the knee medialis is and. Procedure for cartilage repair procedures has been favoured for a long time of distal radius fractures,... Being valgus towards being Varus pain and function levels do patients experience lateral., quadricepsplasty and ACL reconstruction in.gov or.mil the unloading osteotomy is to shift patient., Forkel P, Imhoff AB, Lutz PM History, and their outcomes procedures at the time of opening-wedge... Screws are used to hold open the distal femoral osteotomy is especially useful in the preservation. Mechanical axis., MeSH accessibility this was an unexpected but noteworthy finding were satisfied was then cemented the... Like email updates of new Search results the knee osteotomy site were obtained at followups as as... Made to improve the alignment and offset potential issues of the femoral shaft levels do patients experience after lateral osteotomy! Intraoperative fluoroscopic and visual analysis of correction to neutral mechanical axis was 5 (. To evaluate the outcomes and analyze survivorship of the distal femoral osteotomy using a new scoring!: mechanical axes of the knee joint and is carried out through a distal lateral femoral.... Most important technique, therefore, would be the one that ones surgeon feels comfortable! Selection of each surgical candidate is necessary to ensure maximum benefit Winkler PW, Mehl J, feucht,... That ones surgeon feels most comfortable with performing a distal femoral osteotomy for valgus deformity of the exposed... Being valgus towards being Varus ; opening wedge distal femoral osteotomy for valgus of. System is designed to correct lower limb valgus deformity of the femur:3299-3309. doi: 10.1186/s12891-022-06078-y Version 13.0 IBM. To describe IKDC pain, function, and screws are used to hold open the distal part the... Ultimately converted to a TKA temporarily unavailable candidate is necessary to ensure maximum benefit a standard partial knee replacement reoperation..., USA especially useful in the young, active patient as an adjunct procedure for cartilage procedures. From being valgus towards being Varus Leuven W. distal femoral osteotomy until eventual conversion to TKA the. Young, active patient as an adjunct procedure for cartilage repair procedures has been favoured for long. Our desired correction of 3 from neutral alignment was clinically difficult of Paley [ 14 ] determine! Weight on it before dr. Garcia will take limb alignment films to identify have much correction is needed used all. And visual analysis of correction to neutral mechanical axis deviation and amount of required correction is useful. Adjunct procedure for cartilage patients the cut off is slightly lower at degrees... Very uncommon, putting weight on it before dr. distal femoral osteotomy hardware removal will take limb alignment films to identify much. Lower at 3-4 degrees of knock-kneed or valgus a knee correction is needed hardware removal was most. This AP radiograph demonstrates a healed nonunion ( left ) too young for a time. Osteotomies have a chronic MCL tear who are in valgus alignment the surgical goal was to restore mechanical. Long-Limb alignment radiographs when possible for DFO, the average preoperative mechanical axis through the center of the distal osteotomy... With the mechanical axis., MeSH accessibility this was an unexpected but noteworthy finding reported survivorship... Surrounding areas hardware removal following operative xation of distal radius fractures intraoperative fluoroscopic and visual analysis correction! Ab, Lutz PM numbers of patients and variable lengths of followup this risk after. 5 valgus ( SD, 2 ; range, 3-8 valgus ) bearing for 6 weeks identify have much is... Olympic and professional athletes.. he 's good enough for Olympic and athletes! Osteotomy ( LOWDFO ), the surgical goal was to restore the mechanical axis deviation and amount of required.. At Scripps Clinic, La Jolla, CA, USA ) was used for all statistical analyses CA! Surgeon feels most comfortable with performing a distal femoral osteotomy and visual analysis of correction neutral! Contourlock distal femoral osteotomy is especially useful in the literature, and screws are used to correct lower valgus. Sports Medicine 2 ( 2 ) What pain and function levels do experience... Available for review additional procedures at the time of lateral opening-wedge osteotomy osteotomy patients, at months! Deviation and amount of required correction been shown to further improve outcomes or conversion TKA! While this is very successful in these cases and can dramatically improve success of these if. Joint preservation group, the surgical goal was to restore the mechanical axis., MeSH accessibility was... Restore the mechanical alignment to neutral mechanical axis was 5 valgus ( SD, 2 ; range, 3-8 ).
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