Distal Femoral Osteotomy (DFO)
Rehabilitation
Rehabilitation Philosophy
This protocol is criteria-based and biologically informed, designed to optimise recovery following distal femoral osteotomy while protecting osteotomy healing and fixation.
Timelines are guides only, progression is dictated by radiographic union, symptom response, limb alignment control, and functional strength, not time alone.
Key Biological Considerations
Femoral osteotomy heals more slowly and is less tolerant of early load than tibial osteotomy
Bone healing is the primary rate-limiting step
Strength and impact progression must follow confirmed radiographic union
Emphasis is placed on movement quality, alignment control, and load symmetry
Clinical Governance & Escalation
Persistent pain at the osteotomy site, swelling, loss of motion, gait regression, or failure to progress warrants immediate load modification and review with Dr Lynskey.
Preoperative Phase (Prehabilitation)
Goals
Full knee extension
Voluntary quadriceps activation
Optimisation of hip abductor and core strength
Patient education regarding:
Prolonged protection phase
Slower recovery compared with HTO
Phase 1 – Strict Protection (0–8 Weeks)
Goals
Protect femoral osteotomy and fixation
Maintain full knee extension
Control pain and swelling
Preserve quadriceps activation
Weight Bearing
Typically non-weight bearing → very limited partial weight bearing
Protection phase is longer than for HTO
Progression only as directed by surgeon
Rehabilitation Focus
Active knee ROM within comfort
Quadriceps sets and straight leg raises
NMES for quadriceps inhibition if required
Heel props and extension stretches
Hip abductor and core strengthening
Upper-body and non-weight-bearing conditioning
Avoid
Impact or torsional loading
Aggressive closed-chain strengthening
Early gait endurance work
Phase 2 – Progressive Loading (8–14 Weeks)
(Following evidence of radiographic union)
Goals
Gradual reintroduction of load
Restore functional knee ROM
Begin gait normalisation
Rehabilitation Focus
Progress to WBAT only once cleared
Closed kinetic chain strengthening:
Sit-to-stand
Supported mini-squats
Stationary cycling
Balance and proprioceptive training
Monitor Closely
Distal femoral pain
Swelling response
Gait deviation or protective patterns
Phase 3 – Strength & Capacity (3–6 Months)
Goals
Restore limb strength
Improve neuromuscular and alignment control
Increase functional tolerance
Rehabilitation Focus
Progressive resistance training
Emphasis on hip abductor and trunk control
Step-down and frontal-plane control
Dynamic balance and controlled loading
Phase 4 – Advanced Function (6–12 Months)
Goals
Restore higher-level functional capacity
Prepare for selected recreational activities
Rehabilitation Focus
Higher-load strengthening
Directional and alignment control drills
Low-level plyometrics only after confirmed radiographic union and excellent control
Return To Activities (Criteria-Based)
Required Criteria
Radiographic union
No focal distal femoral tenderness
Minimal or no effusion
Independent, non-antalgic gait
Adequate strength for functional tasks
Encouraged
Walking
Cycling
Swimming
Gym-based strengthening
Cautioned / Often Discouraged
Running
Impact and pivoting sports
(Often delayed long-term or discouraged depending on indication and cartilage status)
Surgeon Notes (VBJS)
Bone healing is the rate-limiting step following DFO
Temporary muscular discomfort is expected; focal bony pain is not
Strength progression should always follow imaging confirmation of union
Modify rehabilitation for:
Biplanar osteotomy
Concomitant cartilage or meniscal procedures
Smoking or metabolic risk factors
Concerns regarding delayed union, pain regression, or functional decline should prompt early review with Dr Lynskey
Key Clinical Message
Early controlled movement maintains joint mobility, but progressive strengthening and load exposure must follow confirmed bone healing to ensure durable outcomes after distal femoral osteotomy.
