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Femoral OsteotomyeMedicine from WebMD
Last Updated: July 13, 2006
AUTHOR
INFORMATION Author:
Austin T Fragomen, MD, Instructor of Orthopedic Surgery, Weill Medical College of
Cornell University; Consulting Surgeon, Department of Orthopedic Surgery,
Limb Lengthening and Reconstruction Svc, Hospital for Special Surgery Coauthor(s):
S Robert Rozbruch, MD, Assistant Professor of Orthopedic Surgery, Weill Medical
College of Cornell University; Consulting Surgeon, Department of Orthopedic
Surgery, Limb Lengthening and Reconstruction Svc, Hospital for Special Surgery Austin
T Fragomen, MD, is a member of the following medical societies: American
Academy of Orthopaedic Surgeons, and Arthroscopy Association of North America Editor(s):
Steven I Rabin, MD, Clinical Associate Professor, Loyola University Medical
Center; Chair, Department of Orthopedic Surgery, Dreyer Medical Clinic; Francisco
Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; B Sonny Bal, MD, Assistant Professor,
Department of Orthopedic Surgery, University of Missouri School of Medicine; Dinesh
Patel, MD,
Assistant Clinical Professor of Orthopedic Surgery, Harvard Medical School;
Chief of Arthroscopic Surgery, Department of Orthopedic Surgery,
Massachusetts General Hospital; and William L Jaffe, MD, Clinical Professor of
Orthopedic Surgery, New York University School of Medicine; Vice Chairman,
Department of Orthopedic Surgery, Hospital for Joint Diseases INTRODUCTION Proximal
femoral osteotomy is currently commonly used for adults in the treatment of
hip fracture
nonunions and malunions and in cases of congenital and acquired hip
deformities. History
of the Procedure: Proximal
femoral osteotomy was a technique used in adults in the early part of the
20th century for the treatment of hip dysplasia and osteoarthritis. Varus and
valgus- producing osteotomies were aimed at maximizing joint congruity and
redistributing the weightbearing load across the femoral head to a less
affected area. Historically, the best results were obtained in patients with
long-standing deformities, including Perthes osteonecrosis, coxa vara, and
developmental dysplasia. Modern periacetabular osteotomies and joint
arthroplasty techniques have narrowed the indications for this once common
procedure. Proximal femoral osteotomy continues to find application in adults
for the treatment of hip fracture nonunions and malunions and in cases of
congenital and acquired hip deformities. Problem:
In young
patients with symptomatic hip disease, total joint arthroplasty has traditionally
been a suboptimal solution. Problems with accelerated bearing wear and
premature implant loosening leading to early revision surgery are well
documented in this patient population. Intertrochanteric osteotomy has some
use in providing temporary relief of pain in this challenging group of
patients. While newer bearing materials with improved wear properties may
improve the longevity of total joints in young patients, data to support this
position are yet lacking. Patients
with deformity of the proximal femur typically develop arthritis over time
due to abnormal joint wear from malalignment. Deformities typically include a
varus or valgus neckshaft angle, rotational malalignments, and leg-length
discrepancy in any combination. These deformities can be acquired, as in the
case of proximal femur fracture malunions and nonunions, or developmental, as
in the cases of fibrous dysplasia, coxa vara, and developmental dysplasia. Regardless of the etiology, these
patients with femoral deformity are at an increased risk for the development
of pain and arthritis in the affected hip. Once arthritis has begun, the
problem is further aggravated by the mechanical malalignment from the femoral
deformity. Standard hip replacement techniques and prostheses are usually unsuitable for
deformed proximal femora, thus increasing the complexity of the procedure,
surgical risks, and possiblythe longevity of the reconstructed joint. The
benefits of early proximal femoral osteotomy to correct deformity are
two-fold. One, in the deformed hip prior to the onset of arthritic changes,
the realignment often reduces symptoms, prevents further joint degeneration.
In the deformed hip with arthritic changes, restoration of normal alignment
can often decreases pain and improves function. Moreover, if the relief of
symptoms is incomplete and the patient later requires hip replacement
surgery, then the arthroplasty procedure is simplified by restoration of the
anatomy. Frequency:
Proximal
femoral osteotomy is commonly used in the treatment of nonunions of hip
fractures. Both femoral neck and intertrochanteric fracture nonunions respond
positively to valgus-producing realignment osteotomies. Malunions of hip
fractures, including intertrochanteric type and unreduced slipped capital
femoral epiphysis (SCFE), are other common indications for osteotomy.
Infrequently, proximal femoral osteotomy is performed in adults for the
treatment of hip arthritis and osteonecrosis. Pathophysiology: Femoral
neck nonunion In
femoral neck nonunion, the fracture fails to heal despite an adequate blood
supply. Weightbearing forces across a vertically oriented fracture line
produce shear stresses at the fracture site that favor the production of
fibrous tissue. Valgus intertrochanteric osteotomy reorients the fracture
site into a more horizontal position. Axial loading in this situation
encourages osteogenesis and fracture union (see Images 1-3). Intertrochanteric
nonunion Intertrochanteric
hip fractures typically do not disturb the blood supply to the femoral head
and tend to heal predictably. Nonunions of this common fracture pattern are
usually the result of a combination of varus malalignment and inadequate
stability of fixation. Treatment is aimed at correcting the varus neck-shaft
angle to a neutral or slight valgus orientation and improving the stability
at the fracture site often with a fixed-angle device (see Images 4-6). Intertrochanteric
malunion When
the fracture collapses into varus angulation and then goes on to bony union,
a malunion results. The hallmark of this malunion is a varus neck-shaft angle
with shortening of the ipsilateral femur, shortening of the abductor
musculature or lever arm, and often trochanteric-pelvic abutment and a
Trendelenburg gait with poor hip motion. This patient is at an increased risk
for the development of hip arthritis. Intertrochanteric osteotomy serves to
realign the hip joint, restore normal abductor mechanics, and reestablish
equal leg lengths. SCFE
malunion SCFE
is a common fracture variant seen in the adolescent population. In many
cases, in situ pinning of the displaced fracture is indicated, since this
reduces the risk of osteonecrosis of the femoral head. If a displaced slipped
epiphysis heals in situ, a fracture malunion can result. After remodeling,
this malunion is characterized by coxa vara, femoral shortening, and
retroversion of the femoral neck with a significant loss of hip motion. A
valgus-producing proximal femoral osteotomy can correct the varus and
reestablish normal rotation, both of which reorient the femoral head in the
acetabulum, offering possible protection from the development of arthritis.
This procedure also equalizes limb length and abductor tension, thereby
normalizing gait. Fibrous
dysplasia A
shepherd's crook deformity of the proximal femur has long been associated
with fibrous dysplasia. Repeated microfractures of the femoral neck lead to
progressive displacement and healing of the femur in varus. Significant
shortening of the femur, trochanteric-pelvic abutment, and shortening of the
abductor lever arm occur concomitantly. Rotational deformity may also be
present. Patients
report limb shortening, hip stiffness, and an inability to abduct the lower
extremity, which can be particularly troublesome for women of childbearing
age. Pain may be present as well. These patients are at risk for progression
of the deformity, fracture of the femoral neck, and joint degeneration.
Valgus-producing proximal femoral osteotomy serves to prevent progression of
the deformity and the development of a fracture, reestablish a more normal
femoral headacetabular relationship, lengthen the extremity, tension the
abductors, and greatly improve hip abduction. Developmental
dysplasia of the hip Adults
with hip dysplasia often have both acetabular and femoral deformity. The
femoral neck assumes a valgus and anteverted orientation, while the
acetabulum is shallow with varying degrees of uncovering of the femoral head,
ranging from mild to subluxed to a frank dislocation. In select patients,
surgery is indicated to improve femoral head coverage or better reduce the
hip joint. A varus-producing proximal femoral osteotomy with derotation of
the anteverted neck improves femoral head orientation. Often, this is
combined with a periacetabular osteotomy to improve superolateral and
anterior head coverage. Osteoarthritis
and osteonecrosis The
goal of the femoral osteotomy procedure is to alter the contact point across
the articular cartilage during weight bearing. When arthritic change occurs
without deformity, then a valgus-extension osteotomy moves the contact point
of weight bearing forces to a new location on the femoral head, alleviating
the pressure across the degenerated area of articular cartilage. This area of
damaged cartilage has been shown to undergo a reparative process through
which new collagen is created (see Images 7-8). Clinical: Adults
present with deformity about the hip from any number of etiologies, including
hip fracture nonunion or malunion including SCFE, congenital coxa vara,
shepherd's crook deformity from fibrous dysplasia, excessive femoral
anteversion, developmental dysplasia of the hip, congenital or acquired
femoral shortening, and soft tissue contractures about the hip. A
thorough examination is crucial before undertaking any osteotomy procedure to
correct a deformity, as deformities commonly lie in multiple planes. Hip,
knee, and ankle are examined, looking for deformity and joint range of
motion. Hip joint contractures may be resolved through the osteotomy.
Rotational profile of the lower extremity, including hip internal and
external rotation and thigh foot axis, is documented. Limb length discrepancy
is measured using blocks and later with radiographs. Previous
incisions, skin quality, and any signs of previous sepsis should be carefully
sought. INDICATIONS The
bases for performing a proximal femoral osteotomy can vary. In the presence
of deformity, the goal is to correct the deformity and in so doing, realign the
hip and lower extremity. This may include frontal, sagittal, and rotational
corrections and perhaps even lengthening through the osteotomy. Indications
for proximal femoral osteotomy in adults include the following: · Nonunion of a femoral neck
fracture · Nonunion or malunion of an
intertrochanteric hip fracture deformity
· Combinations of the above
indications, as in intertrochanteric fracture malunion with varus, external
rotation, and shortening deformity · Simultaneous femoral
osteotomy and total hip arthroplasty · Hip osteoarthritis or
osteonecrosis in the young, active patient RELEVANT
ANATOMY AND CONTRAINDICATIONS Relevant
Anatomy: Proximal
femoral osteotomy is a joint-sparing procedure that relies on maintaining the
biological integrity of the femoral head. Preserving the blood supply to
femoral head is of the utmost importance. In adults, the medial femoral
circumflex artery is the predominant nutrient vessel supplying the femoral
head. Proximal femoral osteotomy is performed via a lateral approach,
reducing the chance of injury to this vessel. Other
relevant anatomy includes knowledge of the normal anatomy of the femur.
Normal neck-shaft
angle ranges from 124-136. The center of the femoral head lies at a similar
height as the tip of the greater trochanter. A line connecting these 2 points
makes an angle of 90 (range 85-95) with the mechanical axis of the femur. Contraindications: · The presence of infection may
preclude the use of internal fixation; however, exte rnal fixation may be a
viable option in such cases. · Limitations of hip motion can
make realignment unsuccessful without soft tissue releases or compensation
through the osteotomy. · Advanced osteoarthritis or
osteonecrosis is a relative contraindication. · Inflammatory arthritis can also
be a contraindication. WORKUP Lab
Studies: · Obtain a white blood cell count,
erythrocyte sedimentation rate, and C-reactive protein level if infection is
suspected. · If osteonecrosis is present,
then an investigation of the etiology may be indicated. · Routine preoperative blood work
is indicated. Imaging
Studies: · Radiography
· Bone scanning
· CT scanning (helpful in some
instances): Hip CT scanning can help confirm the presence of a nonunion. · MRI: This can help assess for
osteomyelitis and can evaluate the condition of the hip joint. TREATMENT Medical
therapy: For painful hip arthritis, treatment
includes nonsteroidal anti-inflammatory drugs, acetaminophen, and glucosamine/chondroitin.
Caution should be exercised when prescribing any medication on a long-term
basis. Bisphosphonates may have a role in optimizing patients for surgery who
have metabolic bone disease. Surgical
therapy: Alternatives
to osteotomy in patients with arthritis include the following: · Total hip replacement: The
age indication for hip arthroplasty continues to broaden for patients with
coxarthritis. This is in a large part due to the good results obtained
through the use of alternative bearing surfaces. Hip arthroplasty has also
been successful in the treatment of patients with femoral neck nonunions,
developmental dysplasia of the hip, and fibrous dysplasia. · Resurfacing procedures · Hip arthroscopy · Distraction arthroplasty
hip joint: This has been successful in children with Perthes disease and may
have a role in adults. Preoperative
details: · Review all information from
history, physical examination, and imaging studies. · Correlate the radiographic
measured degree of deformity with the clinical examination findings. · Optimize the patient's
range of motion and function; do not simply treat based on the radiograph
findings. · If using a blade plate,
determine the optimal position for the blade in the femoral neck based on
radiographic findings. · Plan the level of osteotomy. · Consider best approach with
regard to skin condition. · Have correct
instrumentation available to remove old hardware. · Obtain medical clearance
and achieve patient optimization prior to surgery. · Involve the patient and the
family in the decision-making process. · Provide the patient with
realistic expectations from the surgery. Intraoperative
details: Have
the following items available in the room: the patient's radiographs, a
goniometer, Steinman pins to judge rotation, C-arm fluoroscopy, and a broken
hardware removal set. The operating table should be a fracture table or
Jackson flat table with a bump under the ipsilateral buttock. Internal
fixation The
implant is typically a fixed-angle device (eg, 95 or 130 blade plate), and
the procedure is performed through an open approach with an acute correction.
One surgery is performed, but no postoperative adjustability is possible.
Internal hardware is not ideal in cases of infection. The approach is lateral,
centered over the proximal femur and greater trochanter. If
correcting rotation, place a Steinman pin into the proximal femur
posteriorly, at the level of the lesser trochanter. Place a second pin into
the distal femur at an angle that mimics the deformity such that when the
deformity is corrected the pins will be parallel. Place
guide wire for the blade plate into the femoral neck and head in the
predetermined ideal location. The seating chisel is advanced over the wire
taking care to enter the bone at the ideal angle in the sagittal plane. Any
planned flexion or extension would be set at this time. For valgus osteotomy,
the blade plate can be inserted before completing the osteotomy while the
bone is still stable. The plate is then used to help obtain the correction.
For varus-producing osteotomies, the bone is cut before the blade plate is
inserted (due to impingement of the plate on the femoral shaft), and the
seating chisel is used to help reduce the proximal fragment. The
osteotomy is typically made at the level of the lesser trochanter. With a
valgus-producing osteotomy, a small wedge of bone can be removed to improve
bone contact at the osteotomy site. A compression device can be used, and the
screws are then inserted through the plate. Wounds are closed in layers over
a drain. External
fixation An
external fixator is also a fixed-angle device. It is mounted percutaneously
and can be combined with a percutaneous osteotomy. An acute correction is
typical. The fixator allows for postoperative adjustability, works well in
presence of infection (no internal hardware), and allows for simultaneous
lengthening through osteotomy. However,
the frame may be uncomfortable, a risk of pin tract infection exists, and a
second surgery is required for frame removal. External
fixation is typically reserved for low intertrochanteric or subtrochanteric
osteotomies. When
using external fixation, all half pins are inserted percutaneously. All half
pins are predrilled and then hand inserted to reduce the risk of bone necrosis.
The C-arm is used to establish orientation of the drill to ensure that the
pins are ideally placed. Two
to three pins are used per segment to achieve stability. One half pin is
placed centrally into the femoral neck and head. An additional 1 to 2 pins
are placed above the level of the lesser trochanter. Three to 4 pins are
placed in the shaft of the femur for stability. If
using Ilizarov-type rings, then one ring or ring block is attached to each
segment to mimic the deformity. A percutaneous osteotomy is made, and the
rings are manipulated to place the femur into the desired alignment. If the
rings truly mimic the deformity, then the reduction is obtained by making the
rings parallel. The rings are then fixed to one another. The same correction
can be obtained using a monolateral fixator. Again the frame is mounted in
the deformed position and then acutely or gradually moved into the corrected
position. Postoperative
details: · Drains are removed
postoperative day 1. · Partial weight bearing is
typically allowed immediately. · Wound care is routine. · Showering and pin care
protocols are surgeon specific. Typically showering begins after
postoperative day 4. Follow-up
care: · Office visit at 2 weeks to
remove sutures · Regular monthly visits with
radiographs until bony union is observed · A shoe lift may be
indicated for limb length inequality, or a later limb-lengthening procedure
may be planned if indicated. COMPLICATIONS Major
complications include infection, neurovascular injury, nonunion, inability to
obtain or maintain a full correction, persistence of pain postoperatively,
continued degeneration of hip articular cartilage. Other complications
include deep vein thrombosis and painful hardware. With regard to external
fixation, complications include pin site infection; fracture above or below
the frame and fracture through a screw hole after frame removal, stiffness of
adjacent joints, and septic arthritis if pins communicate with the joint. OUTCOME
AND PROGNOSIS When
proximal femoral osteotomy is used for the correction of congenital and
acquired deformities and repair of hip fracture nonunion, results have been
favorable. Hip range of motion, gait, pain, leg-length discrepancy, and
patient satisfaction are improved. If arthritis develops, then future joint
replacement is often facilitated. Simultaneous femoral osteotomy and total
hip arthroplasty is a technically demanding procedure that has yielded
acceptable results for complex hip reconstruction with deformity. With
regard to the use of proximal femoral osteotomy in the non-deformed hip with
osteoarthritis, long-term followup reveals that many patients go on to
require total hip arthroplasty. Some authors conclude that a place still
exists for osteotomy in the treatment of hip osteoarthritis in younger
patients. However, many have reported on the increased difficulty and higher
complication rates associated with total hip arthroplasty performed in hips
that have FUTURE
AND CONTROVERSIES As
newer prosthetic materials with reduced wear properties prove efficacious in
total hip replacement surgery, the indications for arthroplasty may extend to
younger and more active patients. Short-term follow-up of ceramic-onceramic
total hip arthroplasty has demonstrated encouraging results. Such alternative
bearings could reduce the need for proximal femoral osteotomy. However,
osteotomy will continue to find applications in the correction of PICTURES
Caption:
Picture 1. This
severe vertical fracture line through the femoral neck is a high risk for
nonunion with simple pinning fixation. Picture
Type: X-RAY
Caption:
Picture 2. The
fracture is stabilized with a screw, and then a 95 blade is inserted.
Proximal femoral osteotomy is created and a wedge removed. Picture
Type: X-RAY
Caption:
Picture 3.
Final image showing a valgus-producing osteotomy with improved orientation of
the femoral neck fracture. Picture
Type: X-RAY
Caption:
Picture 4.
Painful nonunion of a peritrochanteric fracture in varus position with
shortening and broken hardware. Picture
Type: X-RAY
Caption:
Picture 5.
Repair of nonunion with a 95 blade plate with restoration of normal alignment
and equalization of limb length. Picture
Type: X-RAY
Caption:
Picture 6.
Osteonecrosis localized to a small area of the weightbearing portion of the
femoral head. Picture
Type: X-RAY
Caption:
Picture 7.
Proximal femoral osteotomy was performed and the head was positioned into more
valgus. In so doing, the affected portion of the femoral head is rotated away
from the weightbearing area. External fixation was selected in this example. Picture
Type: X-RAY
Caption:
Picture 8.
Follow-up radiographs demonstrate a well-healed osteotomy with maintenance of
the valgus positioning. Picture
Type: X-RAY BIBLIOGRAPHY · Barr RJ, Santore RF: Osteotomies
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osteotomy combined with acetabular shelfplasty in young patients with severe
deformity of the femoral head and secondary osteoarthritis. A long-term
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Femoral Osteotomy. Reconstructive Surgery of the Joints 2nd ed. 1996; 1321-32. · McGrory BJ, Estok DM 2nd, Harris
WH: Follow-up of intertrochanteric osteotomy of the hip during a 25-year
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femoral deformity. Clin Orthop 1996; 322: 151-62[Medline]. · Yoo JJ, Kim YM, Yoon KS, et al:
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