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Distal femoral osteotomy

82 citationsUpdated Sep 2026

Overview

Distal femoral varus osteotomy is a well-described surgical intervention for young, active individuals presenting with isolated lateral compartment osteoarthritis and valgus malalignment [1]. It serves as an acceptable option for severe unicompartmental knee osteoarthritis associated with malalignment [3] and a good alternative for lateral tibiofemoral osteoarthritis in a valgus knee [14]. The procedure reliably corrects valgus mechanical alignment, decreases pain, and increases function in patients with lateral compartment disease [12]. While the lateral opening wedge technique is reproducible for limb alignment correction [7], it has no effect on leg length [8]. Although one study noted that lateral opening-wedge correction was less accurate than expected, the procedure remained associated with improved knee pain and function scores [9]. Overall, the lateral opening wedge distal femoral osteotomy remains a versatile and reliable option for addressing limb malalignment in the young population seeking to preserve function and higher activity levels over a period of 10 or more years [7].

The procedure offers favourable midterm results, with good functional recovery reported after 1 year [13]. In a young and active population, distal femoral osteotomy results in high return to sport rates and continuous sports participation even 7 years after the procedure [6]. Both lateral closing wedge distal femoral osteotomy (LCWDFO) and medial closing wedge distal femoral osteotomy (MCWDFO) appear to be safe and effective surgical interventions for improving coronal plane deformity about the knee [17]. Coronal and rotational deformities of the femur can be accurately corrected simultaneously by a distal femoral osteotomy utilizing patient-specific instruments [5]. A preoperative calculated angle for single cut derotational osteotomy at the distal femur leads to a clinically precise post-operative result on torsion and frontal alignment [15].

Specific anatomical considerations influence surgical strategy. Patients with a decreased femoral trochlea axial orientation can have better surgical outcomes after correction by derotational distal femur osteotomy compared to isolated medial patellofemoral ligament reconstruction [10], where a positive malalignment sign serves as evidence for femoral derotation osteotomy [23]. The procedure utilizes an osteochondral allograft to restore the integrity of the femoral condyle and a lateral opening wedge distal femoral osteotomy to correct femoral-based valgus deformity [18]. A combined distal femoral osteotomy and lateral meniscus allograft transplant represents a good option for younger patients looking to avoid knee arthroplasty, provided patient selection and preoperative counseling are of the utmost importance [25]. The use of distal femoral varus osteotomy combined with fresh osteochondral allograft in patients with failed lateral tibial plateau fracture results in the majority of patients having good or excellent clinical outcomes and significantly delays the need for TKA in most patients [32]. The indication for concomitant tibial tubercle osteotomy should be individualized according to each patient's specific anatomical and clinical characteristics [37].

Anatomy & Pathophysiology

Bony Anatomy

The distal femur exhibits distinct morphological asymmetries between the medial and lateral condyles. The medial femoral condyle is larger, projects farther posteriorly and distally than the lateral condyle, and possesses a large, convex articular surface [72, 86]. Conversely, the lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction than the medial condyle [72, 86]. This broader mean anterior-posterior and medial-lateral dimension of the lateral condyle allows internal rotation of the distal femur with knee extension [86]. The medial epicondyle serves as the most anterior and distal osseous prominence of the distal femur [72]. Proximal and posterior to the medial epicondyle lies the adductor tubercle, which is the site of insertion for the adductor magnus muscle [72, 86]. The gastrocnemius tubercle is located slightly distal and posterior to the adductor tubercle [72].

Anteriorly, the trochlear groove separates the femoral condyles and constitutes the patellofemoral articulation [72]. The lateral trochlear facet resists lateral subluxation of the patella [86]. The sulcus terminalis is a small transverse ridge on the lateral femoral condyle just distal to the intercondylar notch that separates the patellofemoral and tibiofemoral articular surfaces [72]. This ridge extends from the oblique facets of the femoral trochlea and is deeper on the lateral condyle than on the medial condyle [86]. The intercondylar notch, which is of variable width, serves as the site of attachment for the cruciate ligaments [72].

The tibial articular surface slopes 7° to 10° in the sagittal plane [72]. The medial tibial plateau is larger than the lateral plateau and is concave in both its frontal and sagittal planes [72]. The posterior slope of the medial tibial plateau averages 10.7° [86]. In contrast, the lateral tibial plateau is smaller, more circular, concave in the frontal plane, and convex in the sagittal plane [72]. The posterior slope of the lateral plateau averages 7.2° [86]. The medial compartment has a large surface area containing a convex femoral condyle and concave tibial plateau, whereas the lateral compartment has a smaller surface area containing a convex femoral condyle and convex lateral plateau in the sagittal plane [86]. The medial and lateral tibial plateaus are separated by the intercondylar eminence and its medial and lateral spinous processes [72].

The tibial tuberosity is the site of attachment of the patellar tendon and is typically located in the midline anteriorly, though it may be slightly lateral [72, 86]. Gerdy’s tubercle, the insertion site of the iliotibial band, is located 2 to 3 cm lateral to the tibial tubercle on the proximal tibia [72, 86]. The proximal fibula articulates with a facet of the lateral cortex of the tibia and is not part of the knee articulation [72]. The fibular head is located a mean of 1.5 cm distal to the joint line, with a range of 6 to 32 mm [86].

The patella is the largest sesamoid bone in the body, averaging 2.5 cm in thickness [72]. It possesses the thickest articular surface in the body, measuring approximately 5 mm in the midportion and 2 mm on the sides [72]. The patellar articular surface contains a vertical, central ridge that separates the broader lateral facet from the medial facet, along with a smaller, more medial facet called the odd facet [72]. The odd facet is a small facet on the distal medial patella that articulates in deep flexion of the knee [86]. Patellar morphology is classified by Wiberg into three types: * Type I: Medial and lateral facets are equal in size [86]. * Type II: The most common type, featuring a medial facet that is smaller and one half the size of the lateral facet [86]. * Type III: The medial facet is so far medial that the central ridge is barely noticeable [86].

Ligaments

The anterior cruciate ligament (ACL) travels from the medial border of the lateral femoral condyle to its insertion site anterolateral to the medial tibial spine [47]. It prevents anterior translation and rotation of the tibia on the femur [47]. The ACL is an intra-articular ligament that is technically extrasynovial as it is surrounded by synovium [84]. It consists of 90% type I collagen and 10% type III collagen [72, 86]. The mean length of the ACL is 33 mm, with a variable range of 22 to 41 mm, and the mean midsubstance width is 11 mm, with a variable range of 7 to 12 mm [72, 84, 86]. The ligament is consistently narrowest in the midsubstance [84].

The femoral attachment of the ACL is a semicircular area on the posteromedial aspect of the lateral femoral condyle, posterior to the lateral intercondylar ridge [72, 84, 86]. This attachment measures 20 mm long and 10 mm wide [72, 86]. The ACL attachment is usually oval in shape, with the anteromedial (AM) bundle arising from the superior and anterior aspects and the posterolateral (PL) bundle arising from the posterior and inferior aspects [84]. The bundles are often separated by the lateral bifurcate ridge, which runs from anterior to posterior on the femur [84]. On a clock-face description based on the posterior outlet of the femoral intercondylar notch, the bulk of the AM bundle is attached between 9.30 and 11.30 o'clock, and the PL bundle between 8.30 and 10 o'clock [84]. The distance on the femur between the centers of the AM and PL bundles varies from 8 to 10 mm [84]. The center of the ACL femoral footprint is 43% of the distance from the proximal to distal articular cartilage margin [76]. The center of the anteromedial bundle is 29.5% of the proximal to distal distance of the lateral femoral intercondylar notch, while the center of the posterolateral bundle is 50% of this distance [76]. The posterior edge of the ACL is 2.5 mm from the posterior articular cartilage border [76]. The direct insertion of the ACL is in a narrow area extending from the intercondylar ridge to a second osseous ridge 4 mm posterior [76].

The tibial attachment of the ACL is a broad, irregular, oval-shaped area located in the anterior intercondylar fossa between the medial and lateral tibial spines [72, 84, 86]. This insertion measures 30 mm long and 10 mm wide [72]. The tibial insertion is 120% larger than the femoral insertion [84]. It is located anterolateral to the medial tibial spine, with some fibers passing deep to the transverse meniscal ligament and some merging with the anterior aspect of the lateral meniscus [84].

The posterior cruciate ligament (PCL) runs from the lateral aspect of the medial femoral condyle to the posterior aspect of the tibia, just below the joint line [47]. It prevents posterior subluxation of the tibia on the femur [47]. The PCL has a mean length of 38 mm and mean width of 13 mm [86]. Its femoral attachment is broad and crescent-shaped on the anterolateral medial femoral condyle, with a mean length of 30 mm and mean width of 5 mm [86]. The tibial insertion of the PCL onto the posterior central sulcus is 10 to 15 mm distal to the joint line of the knee [86]. The PCL consists of two bundles: the anterolateral bundle is stronger and stiffer than the posteromedial bundle [86]. The anterolateral bundle is tight in knee flexion, while the posteromedial bundle is tight in knee extension [86].

The medial collateral ligament (MCL) has superficial and deep portions which stabilize the knee to valgus stresses [47, 92]. The MCL originates on the femoral sulcus approximately 3.2 cm proximal and 4.8 cm posterior to the articular surface of the femur at the knee [86]. The lateral collateral ligament (LCL), also known as the fibular collateral ligament, runs from the lateral femoral condyle to the head of the fibula [47]. It is the main stabilizer against varus stress [47, 92] and is part of the posterolateral “complex” or “corner” of the knee that also resists external rotation [47]. The popliteofibular ligament is present in 90% of knees and runs from the tendon of the popliteus muscle to the styloid on the posterior fibular head [47].

The posteromedial corner resists valgus stress [92], while the posterolateral corner resists posterior translation, external rotation, and varus angulation of the tibia [92]. The posteromedial corner of the knee has five major components: the posterior oblique ligament, the semimembranosus tendon and its expansions, the oblique popliteal ligament, the posteromedial joint capsule, and the posterior horn of the medial meniscus [81]. The posterior oblique ligament is a thickening of the medial capsular ligament attached proximally to the adductor tubercle of the femur and distally to the tibia and posterior aspect of the capsule [81]. Its distal attachment is composed of three arms: the prominent tibial arm, the superior capsular arm, and the poorly defined inferior distal arm [81]. The central portion of the posterior oblique ligament is the thickest and probably the most important arm, originating in the region of the adductor tubercle [81]. The superior arm passes posteriorly, blending with the posterior capsule and the oblique popliteal ligament as it separates from the semimembranosus tendon [81]. The inferior and distal groups of fibers pass superficially over the insertion of the semimembranosus tendon, attach to the tibia and fascia inferiorly, and probably have little functional importance [81].

The semimembranosus tendon has five expansions: the direct arm, the anterior or deep arm, the arm to the posterior oblique ligament or capsular arm, the arm to the oblique popliteal ligament, and the expansion to the popliteus aponeurosis or the inferior arm [81]. The oblique popliteal ligament is a broad fascial band originating from the capsular arm of the posterior oblique ligament and the lateral expansion of the semimembranosus to cross the posterior aspect of the knee [81]. It passes laterally and proximally toward the lateral femoral condyle, attaching laterally to the meniscofemoral portion of the posterior capsule and to the fabella [81]. The posteromedial capsule begins posterior to the superficial and deep MCL [81]. Posteriorly, the deep MCL blends with and becomes inseparable from the central arm of the posterior oblique ligament [81]. The central arm of the posterior oblique ligament forms a thick fascial reinforcement of both the meniscofemoral and meniscotibial portions of the posteromedial capsule with an additional attachment to the medial meniscus [81]. The posterior horn of the medial meniscus is linked to the posteromedial capsule, the deep MCL, the posterior oblique ligament, and the semimembranosus expansion [81]. The posteromedial portion of the medial capsular ligamentous complex is especially important for valgus and rotational stability to the knee [81]. The posteromedial capsule and posterior oblique ligament become progressively relaxed as the knee flexes [81]. With active contraction of the semimembranosus muscle, each of the three arms of the posterior oblique ligament is tense [81]. The central arm of the posterior oblique ligament must be tightened in surgical repair or reconstruction, or passive stability cannot be attained regardless of any other surgical procedures [81].

The joint capsule and the collateral ligaments are the principal extraarticular static stabilizing structures [75]. The capsule is a sleeve of fibrous tissue extending from the patella and patellar tendon anteriorly to the medial, lateral, and posterior expanses of the joint [75]. The menisci are attached firmly at the periphery to the capsule, especially so medially and less so laterally [75]. Laterally, the passage of the popliteal tendon through the popliteal hiatus to its origin on the femoral condyle produces a less secure meniscal attachment than is present medially [75]. The medial capsule is more distinct and well defined than its lateral counterpart [75]. The capsular structures, along with the medial and lateral extensor expansions of the powerful quadriceps musculature, are the principal stabilizing structures anterior to the transverse axis of the joint [75]. The capsule is especially reinforced by the collateral ligaments and the medial and lateral hamstring muscles, as well as by the popliteus muscle and the iliotibial band posterior to the transverse axis [75]. The anteromedial and anterolateral portions of the capsule are relatively thin structures but are reinforced by the medial and lateral patellar retinacular expansions [75]. The anterolateral capsule is also reinforced laterally by the iliotibial band and medially by reinforcing bands extending from the patella as the medial patellofemoral ligament and the medial patellotibial ligament [75]. The medial patellofemoral ligament is more important for patellar stability and runs from the patella near the junction of the middle and superior thirds to the medial femoral epicondyle [75]. Laterally, there are corresponding lateral patellofemoral and lateral patellotibial ligaments supporting the tracking of the patella [75]. The anteromedial and anterolateral portions of the capsule are significant in protecting the anteromedial and anterolateral aspects of the knee against subluxation and rotational excesses [75].

Warren and Marshall divided the knee into three layers: Layer I includes the deep fascia or crural fascia; Layer II is composed of the superficial MCL, various structures anterior to this ligament, and the ligaments of the posteromedial corner; and Layer III is made up of the capsule of the knee joint and the deep MCL [75]. Alternatively, the medial knee is described in three layers: Layer I is deep fascia overlying the vastus medialis tendon, sartorius tendon, and MCL; Layer II is superficial MCL, sartorius, gracilis, and semitendinosus tendons, and posterior oblique ligament; and Layer III is joint capsule, deep MCL, and coronary ligaments [86].

Biomechanical data indicate that the ACL is subjected to peak loads of 170 N during walking and up to 500 N with running [87]. The ultimate strength of the ACL in young patients is about 1750 N [87]. The ACL fails by serial tearing at 10% to 15% elongation [87]. Sectioning the PCL increases contact pressures in the medial compartment and the patellofemoral joint [87].

Classification

Indications and Patient Profile: Distal femoral osteotomy (DFO) is a joint-preserving operation indicated for symptomatic valgus malalignment with isolated lateral compartment osteoarthritis, articular cartilage defects, or focal posttraumatic deformity [66]. This procedure is most commonly performed in young, active patients who wish to delay arthroplasty while preserving native joint kinematics [66]. Distal femoral varus osteotomy with blade-plate fixation can be a reliable procedure for the treatment of lateral-compartment osteoarthritis of the knee associated with valgus deformity [21]. Derotational femoral osteotomy could significantly reduce femoral anteversion and improve subjective knee function [20].

Rotational and Trochlear Classification: A novel classification system for patients with recurrent patellar subluxation and excessive femoral torsion based on segmental femoral torsion analysis was established [113]. Dejour's types B and D with the present of trochlear spur/bump are considered high-grade trochlear dysplasia [34]. The size of the trochlear bump matters and is an indicative of severity [34]. The more anterior and longer (proximal-distal) the trochlear spur/bump, the more abnormal the patella tracking [34].

Hinge Fracture Classification: In lateral closing wedge distal femoral osteotomy, a type 1 hinge fracture is a fracture extending to the medial cortex in line with the osteotomy [143]. A type 2 hinge fracture is a fracture breaching the medial cortex proximally to the osteotomy line [143]. A type 3 hinge fracture is a fracture extending distally from the osteotomy [143]. In lateral closing wedge distal femoral osteotomy, a fracture in line with the osteotomy is classified as an extension type fracture [144]. Fracture lines diverting proximally or distally of osteotomy orientation are classified as proximal or distal type fractures, respectively [144].

Other Considerations: Long limb standing view is the gold standard for varus-valgus alignment evaluation [34]. Computed Tomography (CT) is the gold standard for the evaluation of rotational malalignment including femoral and tibial torsions [34]. EOS, a 3-D X-ray system, is a recent addition to alignment evaluation, but is often not available [34]. TT-TG distance values can vary between CT and MRI, especially because of knee positioning (slight flexion in MRI and full extension in CT) [34]. The classic TTTG distance threshold of 20 mm is somewhat controversial; values 15 mm on MRI are significantly abnormal (2 standard deviations from the population mean) [34].

Femoral anteversion is defined as the angle formed between the axis of the femoral head-neck and the posterior condylar line of the distal femur [68]. Tibiofemoral rotation is determined by comparing the angle between the posterior condylar line of the femur and the posterior condylar line of the tibia [68]. A positive tibiofemoral rotation angle indicates external rotation of the proximal tibia relative to the distal femur [68]. Tibial external rotation is defined as the angle assessing rotational alignment of the distal tibia relative to the proximal tibia [68].

The hip-knee-ankle angle is formed by the mechanical femoral axis and the mechanical tibial axis [145]. The mechanical lateral distal femoral angle is formed by the mechanical femoral axis and the distal femoral joint line [145]. The weightbearing line ratio of the knee joint is calculated as a percentile by dividing the distance from the medial edge of the proximal tibia to the point where the mechanical axis intersects with the proximal tibia by the entire width of the proximal tibia [145].

Clinical Presentation

Indications and Patient Selection

Distal femoral osteotomy (DFO) is a valid option for young, active patients presenting with lateral compartment osteoarthritis or overload and valgus malalignment [51]. The procedure addresses both mechanical correction and the modulation of the inflammatory environment in the joint, making it a critical component of comprehensive treatment for knee pain, malalignment, and cartilage disorders in this demographic [28]. Lateral opening wedge DFO remains a reproducible, versatile, and reliable technique for limb alignment correction in patients with valgus malalignment who wish to preserve function and higher activity levels for 10 or more years [7]. Medial closing wedge DFO (MCW-DFO) is effective for treating pathological valgus knees regardless of the site of the deformity [39]. Lateral opening wedge DFO (LOW-DFO) efficiently manages lateral knee osteoarthritis in young patients with valgus deformity, demonstrating a good survival rate at 10 years and high patient satisfaction [60].

Patellar Instability and Rotational Deformity

In patients with genu valgum, distal femoral osteotomies improve recurrent patellar instability [36]. For patients with patellofemoral instability associated with increased femoral anteversion, derotational distal femoral osteotomy achieves a significant reduction in pain, improves subjective knee function, and provides adequate correction of torsional and coronal alignment [56]. In cases of recurrent patellar dislocation accompanied by excessive femoral anteversion angle and trochlear dysplasia, MPFL reconstruction combined with derotational distal femur osteotomy yields satisfactory clinical outcomes during follow-up [123].

Preoperative Assessment and Imaging

Accurate osteotomy planning requires a complete radiographic examination, including weight-bearing anteroposterior (AP) and lateral views, skyline views, Rosenberg views, and weight-bearing long leg radiographs [51]. The valgus mechanical axis is determined by drawing the weight-bearing line from the center of the femoral head to the center of the ankle joint on the AP view of the long leg radiograph [51]. Trochlear imaging assessment relies on CT and/or MRI, particularly axial and true sagittal views, with the gold standard being a true lateral view radiograph and Dejour's classification [34]. Tibial tuberosity to trochlear groove (TTTG) distance values may vary between CT and MRI due to knee positioning, specifically slight flexion in MRI versus full extension in CT [34]. The classic TTTG distance threshold of 20 mm is somewhat controversial; however, values of 15 mm on MRI are significantly abnormal, representing 2 standard deviations from the population mean [34].

Outcomes and Functional Recovery

Femoral medial closing wedge osteotomy serves as a surgical method for improving symptoms of lateral osteoarthritis in the valgus knee [35]. Correction of valgus knee malalignment through distal femoral varus osteotomy reliably results in improved function and return to sport, provided that concomitant chondral, meniscal, and ligamentous pathology is addressed [59]. Preoperative CPAK phenotype does not affect clinical and radiological outcomes after medial closing-wedge distal femoral osteotomy in valgus knees at 8-year follow-up [62].

Biomechanical and Anatomical Effects

Lateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance [16]. With more tibiofemoral angle correction, more congruence angle correction can be achieved, which requires simultaneous patellar stabilization [27]. Internal tibial torsion seems profoundly responsive to correction of coronal plane deformity [29].

Investigations

Plain radiography: Weight-bearing AP and lateral radiographs assess cartilage loss from the distal femur and tibial plateau [90]. A standing full-length AP radiograph from the hip to the ankle evaluates limb alignment and knee deformity, identifying femoral or tibial bone deformity whether developmental or traumatic [98]. Long leg alignment views determine the mechanical axis; if the axis traverses the involved compartment, realignment may be considered as an initial procedure or adjunct to cartilage restoration [94]. A weight-bearing knee flexed at 45 degrees, imaged posterior to anterior, assesses cartilage loss from the posterior femur and tibial plateau [90]. Patellofemoral views assess patellofemoral alignment, patellar and trochlear morphology, osteochondral injury, and patellofemoral arthritis [90]. Preoperative radiographic imaging predicts leg length change after valgus-correcting distal femoral osteotomy with high reliability [142].

MRI: MRI evaluates articular cartilage morphology [94] and identifies the degree of articular cartilage injury, including chondrosis and full-thickness cartilage loss, as well as associated bone marrow edema [90]. A positive malalignment sign on knee MRI serves as evidence for femoral derotation osteotomy in patients with patellar dislocation [23].

CT: Three-dimensional CT reconstructions may help with preoperative planning for multiplanar osteotomy for limb malalignment [90]. Axial plane imaging of the knee helps assess the rotational alignment of components in cases of patellar maltracking [90]. A pilot 3D computed tomography simulation study evaluated the effect of lateral opening wedge distal femoral osteotomy on TT-TG distance [16].

Other Considerations: Finite element analysis evaluates the stability of the bone-implant construct under physiological loading at various knee flexion angles to determine optimal implant fixation position [4]. Preoperative calculated angles for single cut derotational osteotomy at the distal femur lead to a clinically precise post-operative result on torsion and frontal alignment when using 3D-printed cutting guides [15]. Patient-specific instruments are utilized to accurately correct coronal and rotational deformities of the femur simultaneously by a distal femoral osteotomy [5]. 3D patient-specific instrumentation is used for performing a medial closing wedge distal femoral osteotomy [64]. Computer-assisted surgery has been applied to valgus knees, with a goal to achieve an HKA angle of 179° ± 2° and an MPTMA of 90° ± 2° to avoid an oblique joint line [67]. Individual valgus correction angle for distal femoral resection enhances the accuracy of postoperative limb alignment restoration compared with fixed valgus correction angle [43].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacological interventions for distal femoral osteotomy.

Operative

Indications: Restoration of a neutral mechanical axis corrects maltracking and subluxation by decreasing lateral patellar forces [40]. Concomitant medial arthroplasty (MAT) and distal femoral osteotomy (DFVO) afford a high rate of return to sport at an average of 16.9 months postoperatively, as well as a significant decrease in VAS pain scores [155].

Surgical Approach / Technique: A medial closing-wedge distal femoral osteotomy (MCDFO) with locking plate fixation affords a highly stable construct suitable for early weight-bearing and avoids hardware-related issues associated with lateral opening-wedge osteotomies [19]. By following specific tips, a successful lateral opening-wedge distal femoral osteotomy may be performed safely, effectively, and according to plan [2]. The supracondylar V osteotomy through a lateral approach is a very useful technique because surgical time and blood loss are minimal and it has a short learning curve [38]. The V shape of the osteotomy allows large correction while preserving stability [38]. Correction in wedge-less V-shaped distal femoral osteotomy is obtained by lateral penetration and crushing of the cancellous bone [38]. Mediolateral translation is not necessary for wedge-less V-shaped distal femoral osteotomy because no wedges are taken [38]. Internal fixation with a plate in wedge-less V-shaped distal femoral osteotomy has the advantage of early mobility and rehabilitation, which may reduce patient morbidity and save time compared with correction without a plate [38]. Derotational distal femoral osteotomy is categorized based on the incision location into medial incision and lateral incision [41]. This Technical Note illustrates the preferred technique for performing a medial closing wedge distal femoral osteotomy using 3D patient-specific instrumentation in addition to a patellar osteochondral allograft transplant [64].

Implant Selection: Positioning the plate more posteriorly and avoiding distal placement during MCDFO represents the biomechanically optimal strategy [4]. Interfragmentary micromotion at the osteotomy site decreased consistently as the plate was positioned more posteriorly and more proximally across all tested knee flexion angles [4]. The most favorable outcomes for interfragmentary micromotion and PVMS were identified when the plate was placed in the most posterior and proximal position, with respect to mean stress at the lateral hinge of the distal femur [4]. A posterior and mid-height plate position was found to be advantageous for MCDFO [4]. The improvements in the TriS-MDFO, including the diamond-shaped head, more distally oriented screws, and novel compression hook, may increase the ease and safety of medial closed wedge distal femoral osteotomy [44].

Other Considerations: Surgical failure remains a considerable concern for orthopaedic surgeons performing MCDFO [4]. Hinge fracture, nonunion, malunion, correction loss, and implant breakage are not uncommon and may necessitate additional surgical intervention, resulting in persistent pain, prolonged rehabilitation, and a substantial clinical burden for patients [4]. Forty-nine percent of patients required removal of screws from the osteotomy site [30].

Complications

Intraoperative and Early Postoperative: In a 15-year series of high tibial and distal femoral osteotomies, intraoperative complications occurred at a rate of 1.2% [125], while early postoperative complications (≤90 days) occurred at a rate of 42.0% [125]. Surgeons must remain vigilant for major vascular injury during exposure and osteotomy [152]. Specific risks for medial closing-wedge distal femoral osteotomy include neurovascular injury, deep infection, hematoma, compartment syndrome, failure to properly correct alignment, fracture of the condyle, and nonunion resulting from violation of the lateral cortex [63]. In a patient-specific instrumentation cohort, one patient sustained an intraoperative hinge fracture (intra-articular tibial plateau fracture) treated with open reduction and internal fixation, and another experienced a wound complication requiring irrigation, debridement, and revision closure [108]. No neurovascular injuries were reported in that same patient-specific instrumentation cohort [108].

Hinge Fractures: Medial cortical hinge fractures are a common finding in lateral opening-wedge distal femoral osteotomy, presenting with three distinct fracture types [50]. Hinge fracture is also a surgical failure concern for medial closing-wedge distal femoral osteotomy that may necessitate additional surgical intervention [4].

Union and Healing: Nonunion, malunion, correction loss, and implant breakage are surgical failure concerns for medial closing-wedge distal femoral osteotomy that may necessitate additional surgical intervention [4]. The opening wedge technique for distal femoral osteotomy may have a higher rate of nonunion compared to the medial closing wedge technique [51]. Time to union for opening-wedge distal femoral osteotomy ranged from 3 to 6 months across three studies [53]. No patients experienced nonunion at the osteotomy site postoperatively in a systematic review of derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction [112].

Hardware and Implant Issues: Six patients underwent removal of hardware in a patient-specific instrumentation cohort for corrective high tibial and distal femoral osteotomy [108]. In a reported case, a broken screw migrated to the knee joint after hardware failure following closing wedge distal femoral osteotomy [160]. The lateral opening wedge technique is associated with irritation of the iliotibial band [63], whereas the medial closing wedge technique is associated with a lack of available implants [63]. Biomechanical analysis indicates that positioning the plate more posteriorly and avoiding distal placement during medial closing-wedge distal femoral osteotomy represents the optimal strategy to enhance bone-implant construct stability [4]. Interfragmentary micromotion at the osteotomy site decreased consistently as the plate was positioned more posteriorly and more proximally across all tested knee flexion angles [4]. The most favorable outcomes for mean stress at the lateral hinge were identified when the plate was placed in the most posterior and proximal position [4], with a posterior and mid-height plate position found to be advantageous [4].

Infection: No patients experienced infection postoperatively in a systematic review of derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction [112].

Functional and Mechanical Complications: Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected [9]. Surgical failure after medial closing-wedge distal femoral osteotomy may result in persistent pain, prolonged rehabilitation, and a substantial clinical burden for patients [4].

Reoperation and Revision: Twenty-two percent (5/23) of cases had at least one related, unplanned reoperation in a patient-specific instrumentation cohort for corrective high tibial and distal femoral osteotomy, excluding hardware removal, unrelated fractures, and planned second surgeries [108]. The total survivorship was 91% (21/23 knees) in that cohort [108]. There was no difference in the final change in patient-reported outcomes between the 4 patients who underwent a related reoperation and the rest of the cohort, excluding the patient who underwent total knee arthroplasty [108]. The major complication rate for derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction ranged from 0% to 13.3% with an overall pooled risk of 1.3% (95% CI = 0.3%–3.0%) [112]. Knee stiffness was the most common major complication in the short term after this combined procedure, occurring in 7 of 13 cases (53.8%) [112]. The overall dislocation rate after derotational distal femoral osteotomy combined with medial patellofemoral ligament reconstruction was 1.1% (5/464) [112]. Complication rates for opening-wedge distal femoral osteotomy ranged from 0% to 30% across five studies [53]. High tibial and distal femoral osteotomies have substantial complication rates in the short and mid term, with a higher rate of overall complications observed after distal femoral osteotomy as compared to the high tibial osteotomy cohort [157]. Complications after these procedures are associated with increasing medical comorbidities and tobacco use [157].

Conversion to Total Knee Arthroplasty: Patients who undergo total knee arthroplasty after prior distal femoral osteotomy are at increased risk of postoperative complications and revision surgery compared to primary total knee arthroplasty patients [66]. Ten-year survivorship free from aseptic loosening for total knee arthroplasty after distal femoral osteotomy was 95% [147]. Total knee arthroplasty after distal femoral osteotomy was associated with a high complication rate secondary to problems with balancing the knee [147]. Total knee arthroplasty after varus distal femoral osteotomy can carry an increased risk of intra-operative complications [156], although medium term results are comparable to arthroplasty performed as a primary intervention [156]. Reported rates of conversion from distal femoral osteotomy to total knee arthroplasty vary across series and registries, with reported ranges of 5 to 15% conversion at eight to 15 years of follow-up [66].

Recovery

Functional milestones: Lateral opening-wedge distal femoral osteotomy is associated with improved knee pain and function scores [9]. In a young and active population, distal femoral varus osteotomy for valgus deformity reliably affords the ability to return to work within a relatively short time period, regardless of the occupational demand level [117]. Undergoing isolated lateral closing wedge distal femoral osteotomy for symptomatic femoral-based varus malalignment enabled the vast majority of patients to return to sports and work along with a significant functional improvement at mid-term follow-up [121].

Other Considerations: The 10-year survivorship of distal femoral varus osteotomy demonstrates reliable outcomes that may assist in delaying the inevitable need for total knee arthroplasty [70]. The use of distal femoral varus osteotomy combined with fresh osteochondral allograft in patients with failed lateral tibial plateau fracture results in the majority of patients having good or excellent clinical outcomes and significantly delays the need for total knee arthroplasty in most patients [32]. Psychological readiness to resume sporting activities correlated with knee function and was significantly higher in patients who achieved the preoperative level of sport than in patients who did not [151].

Complications and Hardware: Lateral closing wedge distal femoral osteotomy and medial closing wedge distal femoral osteotomy both seem safe and effective surgical interventions for improving coronal plane deformity about the knee [17]. Surgical failure concerns for medial closing-wedge distal femoral osteotomy include hinge fracture, nonunion, malunion, correction loss, and implant breakage [4]. Complications associated with medial closing-wedge distal femoral osteotomy include neurovascular injury, nonunion due to violation of the lateral cortex, fracture of the condyle, deep infection, failure to properly correct alignment, hematoma, and compartment syndrome [63].

Biomechanics and Alignment Effects: Positioning the plate more posteriorly and avoiding distal placement during medial closing-wedge distal femoral osteotomy represents the biomechanically optimal strategy for minimizing interfragmentary micromotion and plate stress [4]. Spontaneous corrective growth of the opposite epiphyseal plate can result in an inclination of the knee joint line even if the overall leg axis is restored [31].

Key Evidence

  • [Paper] Ideal candidates for distal femoral varus-producing osteotomy are young and active individuals with isolated lateral compartment arthritis and valgus malalignment. [1] (10.1016/j.csm.2019.02.005)
  • [L5] By following these tips, the authors believe that a successful lateral opening-wedge distal femoral osteotomy may be performed safely, effectively, and according to plan. [2] (10.1016/j.eats.2023.08.021)
  • [L4] Distal femoral osteotomy is an acceptable surgical option for the young patient with severe unicompartmental knee osteoarthritis and malalignment. [3] (10.1177/2325967114s00051)
  • [L5] [4] (10.1177/23259671261469346)
  • [L3] Coronal and rotational deformities of the femur can accurately be corrected simultaneously by a distal femoral osteotomy utilizing patient-specific instruments. [5] (10.1177/03635465251314868)
  • [L4] Distal femoral osteotomy performed in a young and active population results in high return to sport rates and continuous sports participation even 7 years after the procedure. [6] (10.1002/ksa.70524)
  • [Paper] The lateral opening wedge distal femoral osteotomy is a reproducible technique for limb alignment correction in patients with valgus malalignment and remains a versatile and reliable option for addressing limb malalignment in the young population that may want to preserve function and higher activity levels over a period of 10 or more years. [7] (10.1016/j.eats.2016.02.037)
  • [L4] Lateral opening wedge distal femoral osteotomy has no effect on leg length. [8] (10.1007/s00167-014-3387-5)
  • [L4] 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. [9] (10.1007/s11999-014-4106-8)
  • [L3] Patients with a decreased femoral trochlea axial orientation can have better surgical outcomes after correction by derotational distal femur osteotomy compared to isolated medial patellofemoral ligament reconstruction. [10] (10.1002/ksa.12193)
  • [L5] Distal femoral varus osteotomy is a well-described treatment option for patients with valgus malalignment associated with a variety of underlying conditions, including isolated lateral compartment osteoarthritis. [11] (10.5435/jaaos-d-16-00179)
  • [Paper] Distal femoral osteotomy can reliably correct valgus mechanical alignment, decrease pain, and increase function in patients with lateral compartment disease. [12] (10.1016/j.eats.2016.08.009)
  • [L4] Distal femoral opening-wedge osteotomy for lateral knee osteoarthritis resulted in good functional recovery after 1 year and favourable midterm results. [13] (10.1007/s00167-016-3988-2)
  • [L4] Distal femoral varus osteotomy is a good alternative for treating lateral tibiofemoral osteoarthritis associated with a valgus knee. [14] (10.1016/j.otsr.2010.04.009)
  • [L5] A preoperative calculated angle for single cut derotational osteotomy at the distal femur leads to a clinically precise post-operative result on torsion and frontal alignment when using this approach. [15] (10.1186/s12891-018-2140-5)
  • [L5] Lateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance. [16] (10.1186/s12891-023-06832-w)
  • [L4] Lateral closing wedge distal femoral osteotomy (LCWDFO) and medial closing wedge distal femoral osteotomy (MCWDFO) both seem safe and effective surgical interventions for improving coronal plane deformity about the knee. [17] (10.5435/jaaosglobal-d-24-00139)
  • [L5] The procedure utilizes an osteochondral allograft to restore the integrity of the femoral condyle and a lateral opening wedge distal femoral osteotomy to correct femoral-based valgus deformity. [18] (10.1016/j.eats.2022.03.014)
  • [Paper] A medial closing-wedge distal femoral osteotomy with locking plate fixation affords a highly stable construct suitable for early weight-bearing and avoids hardware-related issues associated with lateral opening-wedge osteotomies. [19] (10.1016/j.eats.2021.03.013)
  • [L4] Derotational femoral osteotomy could significantly reduce femoral anteversion and improve subjective knee function. [20] (10.1002/ksa.12015)
  • [L4] Distal femoral varus osteotomy with blade-plate fixation can be a reliable procedure for the treatment of lateral-compartment osteoarthritis of the knee associated with valgus deformity. [21] (10.2106/jbjs.e.00827)
  • [L4] A positive malalignment sign serves as evidence for femoral derotation osteotomy. [23] (10.1007/s00167-020-06080-8)
  • [L5] A combined distal femoral osteotomy and lateral meniscus allograft transplant represents a good option for younger patients looking to avoid knee arthroplasty, provided patient selection and preoperative counseling are of the utmost importance. [25] (10.1016/j.csm.2019.02.007)
  • [L4] With more tibiofemoral angle correction, more congruence angle correction can be achieved, requiring simultaneous patellar stabilization. [27] (10.1186/1749-799x-4-15)
  • [L5] Osteotomy is a critical part of comprehensive treatment of young patients with knee pain, malalignment, and cartilage disorders, as it addresses both mechanical correction and the modulation of the inflammatory environment in the joint. [28] (10.1016/j.arthro.2023.08.009)
  • [L4] Internal tibial torsion seems profoundly responsive to correction of coronal plane deformity. [29] (10.5435/jaaosglobal-d-19-00009)
  • [L4] Forty-nine percent of patients required removal of screws from the osteotomy site. [30] (10.1177/0363546509357682)
  • [L4] Spontaneous corrective growth of the opposite epiphyseal plate can result in an inclination of the knee joint line even if the overall leg axis is restored. [31] (10.1007/s001670050022)
  • [L4] The use of distal femoral varus osteotomy combined with fresh osteochondral allograft in patients with failed lateral tibial plateau fracture results in the majority of patients having good or excellent clinical outcomes and significantly delays the need for TKA in most patients. [32] (10.1007/s00167-013-2828-x)
  • [L5] [34] (10.1016/j.jisako.2024.100347)
  • [L4] The femoral medial closing wedge osteotomy is a surgical method for improving symptoms of lateral osteoarthritis in the valgus knee. [35] (10.1007/s00167-014-2953-1)
  • [L4] [36] (10.1016/j.jisako.2024.100318)
  • [L4] The indication for concomitant tibial tubercle osteotomy should be individualized according to each patient's specific anatomical and clinical characteristics. [37] (10.1186/s13018-025-06646-7)
  • [L4] [38] (10.1016/j.eats.2025.103954)
  • [L3] MCW-DFO is an effective procedure for treating pathological valgus knees, regardless of the site of the deformity. [39] (10.1177/03635465241262437)
  • [Paper] Restoration of a neutral mechanical axis corrects maltracking and subluxation by decreasing lateral patellar forces. [40] (10.1016/j.eats.2017.08.012)
  • [L3] [41] (10.1186/s12891-026-09485-7)
  • [L2] Individual VCA for distal femoral resection enhances the accuracy of postoperative limb alignment restoration compared with fixed VCA. [43] (10.1007/s00167-014-3496-1)
  • [Paper] The improvements in the TriS-MDFO, including the diamond-shaped head, more distally oriented screws, and novel compression hook, may increase the ease and safety of medial closed wedge distal femoral osteotomy. [44] (10.1016/j.eats.2021.02.016)
  • [L3] Medial cortical hinge fractures in LOW-DFO are a common finding with three distinct fracture types. [50] (10.1007/s00167-020-06244-6)
  • [L4] [51] (10.1016/j.csm.2019.02.004)
  • [L4] [53] (10.1177/2325967116649901)
  • [L4] In patients with PFI and an associated increased FA, D-DFO achieved a significant reduction in pain, an improvement of subjective knee function, as well as an adequate correction of torsional and coronal alignment. [56] (10.1007/s00167-022-07150-9)
  • [L3] Correction of valgus knee malalignment through distal femoral varus osteotomy can reliably result in improvement in function and return to sport, provided that concomitant chondral, meniscal, and ligamentous pathology is addressed. [59] (10.1177/2325967116s00132)
  • [L3] LOW-DFO is an efficient procedure to manage lateral knee osteoarthritis in young patients with valgus deformity, with a good survival rate at 10 years and high patient satisfaction. [60] (10.1002/ksa.12404)
  • [L3] [62] (10.1002/ksa.12795)
  • [Paper] [63] (10.1016/j.eats.2015.07.012)
  • [L5] This Technical Note illustrates the preferred technique for performing a medial closing wedge distal femoral osteotomy using 3D patient-specific instrumentation in addition to a patellar osteochondral allograft transplant. [64] (10.1016/j.eats.2023.03.010)
  • [L4] [66] (10.1016/j.arth.2026.06.073)
  • [L4] [67] (10.1007/s00167-016-4302-z)
  • [L3] [68] (10.1177/03635465251360785)
  • [L4] The 10-year survivorship demonstrates reliable outcomes that may assist in delaying the inevitable need for total knee arthroplasty. [70] (10.1016/j.arth.2007.01.026)
  • [L4] [108] (10.1177/23259671251409361)
  • [L1] [112] (10.1002/ksa.12021)
  • [L3] A novel classification system for patients with recurrent patellar subluxation and excessive femoral torsion based on segmental femoral torsion analysis was established. [113] (10.1186/s13018-024-05123-x)
  • [L3] In a young and active population, DFVO for valgus deformity reliably affords the ability to return to work within a relatively short time period, regardless of the occupational demand level. [117] (10.1177/2325967120965966)
  • [L4] Undergoing isolated LCW-DFO for symptomatic femoral-based varus malalignment enabled the vast majority of patients to return to sports and work along with a significant functional improvement at mid-term follow-up. [121] (10.1007/s00167-022-07303-w)
  • [L3] MPFL reconstruction combined with derotational distal femur osteotomy showed satisfactory clinical outcomes during follow-up in patients with recurrent patellar dislocation who had excessive femoral anteversion angle and trochlear dysplasia. [123] (10.1007/s00167-023-07476-y)
  • [L4] These 15-year data revealed a low rate of intraoperative complications (1.2%) and a relatively high rate of early (≤90 days) postoperative complications (42.0%) after an HTO or DFO procedure. [125] (10.1177/03635465231183092)
  • [L3] Preoperative radiographic imaging can be used to predict leg length change after valgus-correcting DFO with high reliability. [142] (10.1177/23259671251414156)
  • [L4] [143] (10.1007/s00167-020-06197-w)
  • [L4] [144] (10.1007/s00167-021-06466-2)
  • [L3] [145] (10.1177/03635465211031434)
  • [L3] Ten-year survivorship free from aseptic loosening was 95% with reliable improvement in clinical function, though there was a high complication rate secondary to problems with balancing the knee. [147] (10.1302/0301-620x.101b6.bjj-2018-1334.r2)
  • [L3] Psychological readiness to resume sporting activities correlated with knee function and was significantly higher in patients who achieved the preoperative level of sport than in patients who did not. [151] (10.1186/s12891-025-08348-x)
  • [L4] Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy. [152] (10.1007/s00167-022-06996-3)
  • [L4] Concomitant MAT and DFVO afforded a high rate of RTS at an average of 16.9 months postoperatively, as well as a significant decrease in VAS pain scores. [155] (10.1016/j.arthro.2019.07.022)
  • [L3] TKAs after VrDFO can carry an increased risk of intra-operative complications, but medium term results are comparable to arthroplasty performed as a primary intervention. [156] (10.1007/s00167-017-4487-9)
  • [L3] HTO and DFO have substantial complication rates in the short and mid term, with a higher rate of overall complications observed after DFO as compared to the HTO cohort. [157] (10.1007/s00167-022-06865-z)
  • [Case_report] The report aims to provide a lesson to surgeons regarding the unexpected complication of broken screw migration to the knee joint after hardware failure. [160] (10.1186/s12891-019-2505-4)

See Also

References

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[10] Decreased femoral trochlea axial orientation corrected by derotational distal femur osteotomy in patients with patellar dislocation yields satisfactory outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12193

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[32] Distal femoral varus osteotomy combined with tibial plateau fresh osteochondral allograft for post‐traumatic osteoarthritis of the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-013-2828-x

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[36] Distal femoral osteotomies improves recurrent patellar instability in patients with genu valgum: A systematic review. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.100318

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[38] Wedge‐less V‐Shaped Distal Femoral Osteotomy Through Lateral Approach to Correct Valgus Malalignment. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103954

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[112] Derotational distal femoral osteotomy improves subjective function and patellar tracking after medial patellofemoral ligament reconstruction in recurrent patellar dislocation patients with increased femoral anteversion: A systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12021

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[121] Favorable rates of return to activity and work following lateral closing wedge distal femoral osteotomy for femoral‐based symptomatic varus malalignment: an analysis at a mean 6‐year follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-022-07303-w

[123] Derotational distal femur osteotomy combined with medial patellofemoral ligament reconstruction yields satisfactory results in recurrent patellar dislocation with excessive femoral anteversion angle and trochlear dysplasia. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07476-y

[125] Early Postoperative Complications and Associated Variables After High Tibial Osteotomy and Distal Femoral Osteotomy: A 15-Year Experience From a Single Academic Institution. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231183092

[142] Predicting Leg Length Change After Valgus-Correcting Lateral Opening-Wedge Versus Medial Closing-Wedge Distal Femoral Osteotomy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251414156

[143] Hinge fracture in lateral closed‐wedge distal femoral osteotomy in knees undergoing double‐level osteotomy: assessment of postoperative change in rotational alignment using CT evaluation. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06197-w

[144] Dislocated hinge fractures are associated with malunion after lateral closing wedge distal femoral osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06466-2

[145] Detection of Lateral Hinge Fractures After Medial Closing Wedge Distal Femoral Osteotomy: Computed Tomography Versus Plain Radiography. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211031434

[147] Total knee arthroplasty after distal femoral osteotomy long-term survivorship and clinical outcomes. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b6.bjj-2018-1334.r2

[151] Psychological readiness for return to sport following distal femoral osteotomy in patients with recurrent patellar instability. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08348-x

[152] Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06996-3

[155] Return to Sport and Outcomes After Concomitant Lateral Meniscal Allograft Transplant and Distal Femoral Varus Osteotomy. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2019.07.022

[156] Total knee arthroplasty after varus distal femoral osteotomy vs native knee: similar results in a case control study. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4487-9

[157] Complications after high tibial osteotomy and distal femoral osteotomy are associated with increasing medical comorbidities and tobacco use. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06865-z

[160] Case report: migration of a broken screw to the knee joint after hardware failure following closing wedge distal femoral osteotomy. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2505-4

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Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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