Femoral Osteotomy Periprocedural Care

Updated: Mar 11, 2016
  • Author: Austin T Fragomen, MD; Chief Editor: William L Jaffe, MD  more...
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Periprocedural Care

Preprocedural Planning

Planning for a femoral osteotomy should include the following steps:

  • Review all information from the 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 on the basis of the radiographic findings
  • If using a blade plate, determine the optimal position for the blade in the femoral neck on the basis of radiographic findings
  • Plan the level of osteotomy
  • Consider the best approach with regard to skin condition
  • Have correct instrumentation available to remove old hardware
  • Obtain medical clearance, and optimize the patient's status before surgery
  • Involve the patient and the family in the decision-making process
  • Provide the patient with realistic expectations from the surgical procedure
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Preprocedural Evaluation

Adults present with deformity about the hip from any number of etiologies, including hip fracture nonunion or malunion, slipped capital femoral epiphysis (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 to correct a deformity; deformities commonly lie in multiple planes. Hip, knee, and ankle are examined with an eye to deformity and joint range of motion. Hip joint contractures may be resolved through the osteotomy. The rotational profile of the lower extremity, including hip internal and external rotation and thigh foot axis, is documented. Limb-length discrepancy is measured with blocks and, later, with radiographs.

Previous incisions, skin quality, and any signs of previous sepsis should be carefully sought.

In determining the appropriateness of a femoral osteotomy, the appropriate tests and imaging techniques should be performed. 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.

Standing anteroposterior pelvis radiographs may be obtained to measure the neck-shaft angle and assess hip joint integrity. A cross-table view lateral of the involved hip may be warranted to assess sagittal deformity. A standing bipedal 51-in. radiograph, including the top iliac crests down to below the ankle joints, may be done to assess deformity and leg length.

Bone scanning may be done to assess for nonunion or infection. Computed tomography (CT) may be useful in some instances to help confirm the presence of a nonunion. Magnetic resonance imaging (MRI) can help assess for osteomyelitis and can evaluate the condition of the hip joint. According to American College of Radiology Appropriateness Criteria, MRI is the most sensitive and specific imaging modality for diagnosing osteonecrosis of the hip. [13]

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Equipment

The following items should be available in the room when a femoral osteotomy is to be performed:

  • Patient's radiographs
  • Goniometer
  • Steinman pins to judge rotation
  • C-arm fluoroscopy
  • Broken hardware removal set

The operating table should be a fracture table or Jackson flat table with a bump under the ipsilateral buttock.

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Monitoring & Follow-up

The follow-up to a femoral osteotomy includes the following:

  • 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
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