Assessment of return to sport and functional outcomes following distal femoral, double-level and high-tibial osteotomies for active patients with symptomatic varus malalignment

Why this study matters: return to sport, osteotomies & varus malalignment

For active patients with varus malalignment and unicompartmental knee osteoarthritis (UKOA), modern osteotomy surgery aims not only to reduce pain and delay arthroplasty, but also to optimise return to sport (RTS) and functional outcomes. Distal Femoral Osteotomy (DFO), High Tibial Osteotomy (HTO), and Double-Level Osteotomy (DLO) are three key alignment techniques — yet comparative RTS data remain limited.

Study overview: patient cohort, techniques, outcomes measured

This retrospective cohort study analysed 103 active patients with symptomatic varus malalignment and UKOA:

• 19 underwent DFO
  
• 43 underwent DLO
  
• 41 underwent HTO
  

Functional scores, radiographs and sport-activity metrics were collected pre- and post-operatively. Patients were allocated to DFO, HTO or DLO based on deformity location: femoral, tibial, or combined.

Primary outcomes:
• Return-to-sport timing
• Post-operative activity levels
• Functional score improvements

Key findings: high RTS rates, but pre-symptom sport levels not recovered

• All three techniques produced significant functional improvements.
  
• Average time to RTS:
  
  • DFO: 6.4 ± 0.3 months
  • DLO: 4.9 ± 0.2 months
  • HTO: 5.6 ± 0.2 months
    
• No statistically significant differences in RTS timing or functional score improvement across groups.
  
• Despite improvements, pre-symptom sport activity levels were not fully regained in any group.
  
• The authors highlight the need for realistic expectation-setting for active or athletic patients.

Level of Evidence: III (retrospective case-control).

Clinical implications & surgeon take-aways

Keywords: osteotomy planning varus knee, return to sport after HTO/DFO, double-level osteotomy indications, functional rehabilitation knee osteotomy.

• DFO, DLO and HTO all produce favourable RTS rates of roughly 5–6 months.
  
• Correct matching of procedure to deformity location remains essential for optimal biomechanical outcomes.
  
• Patients should be advised that while significant improvements occur, full return to the pre-symptom sport intensity is not typical.
  
• High-quality pre-operative planning, alignment correction, and rehabilitation protocols are key for sport-oriented patients.

Core Findings and Practical Implications

1. Active patients undergoing DFO, DLO or HTO typically return to sport within ~5–6 months.
   
2. All procedures improved functional outcomes, but pre-symptom sport participation was not fully restored.
   
3. Technique selection must be tailored to the anatomical origin of the deformity.
   
4. Managing expectations is essential, especially for athletes seeking high-impact return.
   

Link to full paper: Assessment of return to sport and functional outcomes following distal femoral, double-level and high-tibial osteotomies for active patients with symptomatic varus malalignment

Sources used in report overview:

1. https://www.researchgate.net/publication/371672025_Assessment_of_return_to_sport_and_functional_outcomes_following_distal_femoral_double_level_and_high_tibial_osteotomies_for_active_patients_with_symptomatic_varus_malalignment
2. https://pubmed.ncbi.nlm.nih.gov/37329369/
3. https://link.springer.com/article/10.1007/s00167-023-07457-1