Rotational osteotomies

Rotational osteotomies in either your femur (DFO) and/or your tibia (HTO) can be necessary to obtain a good outcome. All of us have variations in the way we are build, however some persons are build rather extreme. If either your femur or you tibia are rotated too much in either directions, this can cause kneecap problems. 
Femoral (DFO) or tibia rotational osteotomies

Are your hip or thigh bone (femur) turned or rotated too much inwards or outwards? If you kneecaps are pointed towards each other you call this squinting patella. For some people this can lead to anterior knee pain (patellofemoral pain) and/or patella instabiity. By clinical examination this can be ruled out like seen below. However clinical examination is difficult. More precisely this torsional abnormalies can be measured by either CT or MRI of femoral neck + knee + ankle. If your rotation is abnormal and you have significantly problems you can be helped out by derotational osteotomies. Sometimes only the femur (Derotational Femoral Osteotomy = DFO) or only the tibia (High Tibia Osteotomy = HTO) needs to be rotated. Eventually both have to rotated simultaneously.

This girl was severely troubled by anterior knee pain for several years. Physiotherapy guided exercises for hip and knee did not work out. She also tried shoes inlay.

Anteversion of hip

This is a typical example of a young women having had anterior knee pain for several years. Notice how much she can rotate in her hips. In one direction it´s too much, while in the other direction it´s too little. This is due to increases femoral anteversion.

On the picture left you can notice that she her knee caps point inwards. On the picture on the right you can notice that her left knee is not that extreme anymore. Her femur and tibia both were rotated 10 degrees. She previously suffered for chronic anterior knee pain. In a case like this you call it 'miserable malaligment' or better 'tetratorsional malalignment'. Since she was desperate, she had visited several doctors, orthopaedic surgeons as well as several physiotherapist. She was tolded that everything was normal. She had several times been told that she was a hypochondriac and she should consult a psychologist.
Picture at left is a CT scan 3D reconstruction. Try to notice the rotation of the left femur. It is rotated too much. The patient have had recurrent patella dislocation. She had previously undergone MPFL reconstruction, however this failed after a couple of years. She had a derotational femoral osteotomy and a revision MPFL reconstruction and responed positively. However she as most others had to have the plate removed when the osteotomy had healed securely. You can see the x-ray on the right, before the plate was removed.