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Influence of lateral hinge fractures on biplanar medial closing-wedge distal femoral osteotomy for valgus knee: a new classification of lateral hinge fracture



The purpose of this study was to examine the influence of lateral hinge fractures in medial closing-wedge distal femoral osteotomy (MCWDFO) on bone union.


Twenty-one patients were followed-up for more than 1 year after MCWDFO. The incidence and type of hinge fracture, as well as the course of bone healing, were investigated. Slow healing was defined as bone union was not obtained until 3 months after surgery.


Hinge fractures were observed in 12 cases (57%). There were three types of hinge fractures. Type 1: the lateral cortex was completely cut through (4 cases), type 2: the osteotomy line was too proximal (6 cases), and type 3: the hinge point was significantly medial (2 cases). There was a significant difference in the mean correction angles between hinge fracture and no-fracture cases, with the mean angles being 13.8 ± 4.0° and 9.6 ± 3.1°, respectively. Sixty-seven percent (8/12) of cases with hinge fractures developed slow healing. Among the hinge fracture cases, when there was no displacement of the hinge fracture and good contact with the anterior flange, 40% (2/5) of cases developed slow healing. If there was displacement of the hinge or no contact of the anterior flange, 86% (6/7) of cases developed slow healing. In contrast, only 11% (1/9) of subjects who did not have a hinge fracture, developed slow healing. In 67% (6/9) of cases with slow healing, a correction loss of 2° or greater (average: 4.3 degrees valgus) was observed. There were no cases of non-union. Clinical outcomes at 1 year showed no significant difference between the groups with and without hinge fractures.


There is a very high risk of hinge fracture in patients undergoing MCWDFO. Hinge fractures often lead to slow healing and a loss of correction. We recommend the endpoint of the distal lateral cortex of the femur as the ideal hinge point for the prevention of hinge fractures. Bone union is obtained slowly in even all hinge fracture cases without revision surgery. Consequently, surgical results are not affected by the occurrence of hinge fracture at 1 year.

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Availability of data and materials

The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.


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Author information




KF: data collection and analysis, writing paper, helping surgeries. TS: performed surgeries, helping to write the paper. KG: helping surgeries, helping to write the paper. KS: helping surgeries. SI: Helping surgeries.

Corresponding author

Correspondence to Kenji Fujita.

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No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Ethical approval/consent to participate/consent to publish

This retrospective investigational protocol was conducted with the approval of the Ethics Committee of the Toyama Municipal Hospital (IRB No. 2018-22). In accordance with the requirements of this review, all subjects were provided informed consent to participate and publish this study.

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Fujita, K., Sawaguchi, T., Goshima, K. et al. Influence of lateral hinge fractures on biplanar medial closing-wedge distal femoral osteotomy for valgus knee: a new classification of lateral hinge fracture. Arch Orthop Trauma Surg (2021).

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  • Medial closing-wedge distal femoral osteotomy
  • Hinge fracture
  • Bone healing