What Is a DRFO (Distal Femoral Rotational Osteotomy)?

A Distal Femoral Rotational Osteotomy (DRFO) is a joint-preserving surgical procedure used to correct abnormal rotation of the femur (thigh bone) that contributes to hip pain, instability, or labral overload.

While PAO focuses on correcting the position of the hip socket, DRFO addresses problems that originate below the hip joint, in the alignment of the femur itself. In select patients, correcting femoral rotation is essential to restoring healthy hip mechanics and protecting the joint long term.

Why Femoral Rotation Matters

The hip joint functions as part of a larger kinetic chain. Even when the hip socket is well positioned, abnormal femoral rotation can cause the ball of the hip to engage the socket in an inefficient or damaging way.

Excessive femoral anteversion or retroversion can lead to:

Persistent hip pain despite appropriate treatment
Recurrent labral tears
Feelings of instability or giving way
Limited hip motion or mechanical symptoms
Early cartilage wear

In these cases, the issue is not the socket alone — it is how the femur is oriented relative to the pelvis.

What a DRFO Corrects

A DRFO involves carefully cutting and rotating the femur to improve how the hip joint functions during movement. By restoring more normal rotational alignment, the procedure helps reduce abnormal contact forces inside the hip.

This correction can:

Improve joint stability
Reduce stress on the labrum and cartilage
Improve hip range of motion
Allow muscles to function more efficiently

The goal is not simply pain relief, but long-term joint preservation.

Diagram showing rotational correction of the femur during distal femoral rotational osteotomy (DRFO)

DRFO vs PAO: How They’re Different

What PAO Corrects

Periacetabular Osteotomy (PAO) is designed to correct a problem with the hip socket.

In patients with hip dysplasia, the acetabulum is too shallow or improperly oriented, which means the femoral head is not adequately covered. This lack of coverage leads to instability, increased stress on the labrum and cartilage, and accelerated joint wear.

PAO addresses this issue by repositioning the socket to improve coverage and load distribution. By restoring a more normal relationship between the socket and the femoral head, PAO helps stabilize the joint and protect it from further damage.

PAO is most effective when the primary driver of symptoms is structural undercoverage of the socket, particularly in younger patients with minimal arthritis.

What DRFO Corrects

Distal Femoral Rotational Osteotomy (DRFO) addresses a problem with the thigh bone (femur) rather than the socket.

In some patients, the femur is rotated abnormally—either too far inward or outward—causing the hip joint to engage in an inefficient or damaging way during movement. Even when socket coverage is adequate, abnormal femoral rotation can overload the labrum, limit motion, and create a sense of instability.

DRFO corrects this by rotating the femur into a more functional alignment, improving how the ball moves within the socket and how forces are transmitted across the joint.

DRFO is considered when symptoms persist despite appropriate treatment, or when imaging shows femoral rotation that contributes significantly to abnormal hip mechanics.

When PAO and DRFO Are Used
Together

PAO and DRFO are sometimes discussed together because hip mechanics are influenced by both the socket and the femur. In certain patients, correcting only one side of the problem may not fully restore normal joint function.

Some individuals benefit from:

PAO alone, when socket undercoverage is the dominant issue
DRFO alone, when femoral rotation is the primary driver of symptoms
A combined approach, when both socket position and femoral alignment contribute to instability, pain, or joint damage

Determining the correct procedure—or combination—requires a comprehensive evaluation by a hip preservation specialist experienced in complex deformity correction. This includes careful analysis of imaging, joint mechanics, and how the hip functions during real-world movement.

Pelvic X-ray showing surgical correction from periacetabular osteotomy (PAO) and distal femoral rotational osteotomy (DRFO)

When Is DRFO Considered?

A Distal Femoral Rotational Osteotomy (DRFO) is not a routine procedure for hip pain or dysplasia. It is considered when symptoms cannot be fully explained—or corrected—by socket position alone.

In some patients, femoral rotation plays a significant role in how the hip joint functions. Even when socket coverage appears adequate, abnormal femoral version can cause the hip to engage inefficiently during everyday movement, leading to persistent pain, instability, or labral overload.

DRFO may be considered when:

Because femoral version cannot be reliably assessed on standard X-rays alone, determining whether DRFO is appropriate often requires advanced imaging and expert interpretation. Just as importantly, it requires understanding how the hip functions during real-world movement—not just how it looks on scans.

DRFO is considered only when correcting femoral rotation is necessary to restore balanced hip mechanics and protect the joint long term.

Imaging reveals abnormal femoral rotation that alters hip mechanics

Symptoms persist despite appropriate non-surgical care or prior surgery

Labral or cartilage damage appears disproportionate to socket coverage

Patients experience instability, fatigue, or pain that does not improve after PAO or arthroscopy alone

Hip motion feels restricted or mechanically abnormal despite otherwise “corrected” anatomy

Can DRFO Be Performed With Other Procedures?

In some patients, a Distal Femoral Rotational Osteotomy (DRFO) is performed alongside other hip preservation procedures as part of a comprehensive surgical plan. This is most often considered when multiple structural or soft tissue factors contribute to abnormal hip mechanics.

Hip pain and instability rarely stem from a single issue. In carefully selected cases, combining procedures allows each component of the problem to be addressed in a coordinated way:

Hip arthroscopy may be used to treat labral tears or cartilage damage inside the joint.
Periacetabular osteotomy (PAO) corrects inadequate socket coverage and improves joint stability.
DRFO corrects abnormal femoral rotation that alters how the hip moves and bears load.

When performed together, these procedures work synergistically — treating both the source of instability and the secondary damage it creates. This comprehensive approach may offer the best opportunity for durable symptom relief and long-term joint preservation in the right patient.

Not every patient requires a combined procedure. Determining when this approach is appropriate requires careful planning and experience in complex hip deformity correction.

Young female patient resting as part of the recovery process following hip surgery

Recovery After DRFO

Recovery after a DRFO follows the same core principles as other osteotomy-based procedures. Because the femur must heal in its new alignment, early recovery focuses on protection, gradual progression, and guided rehabilitation.

Weight-bearing is limited initially to allow the bone to heal safely. As healing progresses, patients transition through a structured rehabilitation program designed to restore strength and movement without compromising the correction.

Physical therapy emphasizes:

Reestablishing normal movement patterns
Building strength in a controlled, progressive manner
Protecting the corrected alignment as the bone heals

While recovery requires patience, many patients experience meaningful improvement in function, comfort, and confidence once healing is complete. As with all hip preservation procedures, adherence to rehabilitation protocols plays a critical role in long-term success.

Is DRFO Right for You?

Not every patient with hip pain or dysplasia needs a DRFO. This procedure is reserved for specific anatomical patterns where femoral rotation plays a significant role in symptoms or joint overload.

In some cases, patients are told that their imaging “looks normal,” yet pain, instability, or functional limitations persist. In others, symptoms continue despite prior surgery that addressed only part of the problem. When this occurs, abnormal femoral rotation may be an overlooked contributor.

Determining whether DRFO is appropriate requires more than a single scan or checklist. A comprehensive evaluation by a hip preservation specialist includes a detailed clinical exam, advanced imaging, and careful assessment of how the hip functions during real-world movement.

The goal is not to add surgery, but to identify whether correcting femoral alignment is necessary to restore balanced mechanics and protect the joint long term.

Summary

Distal Femoral Rotational Osteotomy (DRFO) is a powerful joint-preserving procedure that corrects abnormal femoral rotation when it contributes to hip pain, instability, or joint damage. Although it is less commonly discussed than PAO, it can be a critical part of achieving lasting hip preservation for the right patient.

The objective is not more intervention — it is the right intervention, tailored to the true source of the problem and performed with long-term joint health in mind.