Editorial Commentary: Distal Femoral Osteotomy Leads to Excellent Outcomes in Patients With Patellofemoral Instability and Valgus Alignment but Should Be Used With Caution.

Recurrent patellar instability is a common problem and especially pronounced in young and active adults. Surgical treatment is preferred over nonoperative treatment, as this reduces redislocations or subluxations and potential cartilage damage, and is associated with increased quality of life. There are several risk factors for patellar instability, which include demographic risk factors (age, gender), soft-tissue imbalances (weak core stability, dynamic valgus, patellar tilt), and underlying anatomic abnormalities (patella alta, increased tibial tubercle trochlear grove distance, coronal malalignment, rotational malalignment, trochlea dysplasia). These risk factors should be routinely assessed in all patients with patellofemoral symptoms using history, physical examination (tracking, J-sign, Q-angle, rotation), and with imaging (standard and long-leg radiographs, magnetic resonance imaging, computed tomography). The cornerstone of surgical management of patellar instability consists of medial patellofemoral ligament reconstruction, and if needed an additional medializing or distalizing tibial tubercle osteotomy and/or lateral retinaculum release or lengthening. In rare cases, additional osteotomies (distal femoral osteotomy, trochleoplasty, rotational osteotomy) are required. Distal femoral osteotomy carries significant risk of complications and could be indicated, rarely, in the setting of patellar instability and severe valgus alignment, and is often considered in revision situations.