Femoral Osteotomy Technique

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

Approach Considerations

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.

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.

Alternatives to femoral osteotomy in patients with arthritis include the following [14] :

  • Total hip replacement - The age indication for hip arthroplasty continues to broaden for patients with coxarthritis, in large part because of the good results obtained through use of alternative bearing surfaces; hip arthroplasty has also been successful in the treatment of 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

Alternative bearings could reduce the need for proximal femoral osteotomy. 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-on-ceramic total hip arthroplasty has demonstrated encouraging results. However, osteotomy will continue to find applications in the correction of deformity in adult patients. [15, 16, 17]

Computer navigation promises to greatly advance the technical accuracy of all osteotomy procedures and will undoubtedly have a profound impact on how proximal femoral osteotomy is performed in the future. [18]

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Femoral Osteotomy

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. Once surgery is performed, 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 so that when the deformity is corrected the pins will be parallel.

Place the guide wire for the blade plate into the femoral neck and head in the predetermined ideal location. Advance the seating chisel 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 (because of impingement of the plate on the femoral shaft), and the seating chisel is used to help reduce the proximal fragment. For proximal femoral varus osteotomy on hips in patients in early stages of Legg-Calve-Perthes disease, Kim et al recommend achieving 10º-15º of varus correction. [19]

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 permits simultaneous lengthening through osteotomy. However, the frame may be uncomfortable, a risk of pin tract infection exists, and a second surgical procedure is required for frame removal.

External fixation is typically reserved for low intertrochanteric or subtrochanteric osteotomies. [20] When external fixation is employed, 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 one to two pins are placed above the level of the lesser trochanter. Three to four pins are placed in the shaft of the femur for stability.

If Ilizarov-type rings are used, one ring or ring block is attached to each segment to mimic the deformity. A percutaneous osteotomy is made, and the rings are manipulated so as to place the femur into the desired alignment. If the rings truly mimic the deformity, the reduction is obtained by making the rings parallel. The rings are then fixed to one another. The same correction can be obtained by using a monolateral fixator. Again, the frame is mounted in the deformed position and then promptly or gradually moved into the corrected position.

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Postoperative Care

Drains are removed on postoperative day 1. In most cases, partial weightbearing is allowed immediately. Wound care is routine. Showering and pin-care protocols are surgeon-specific; typically, showering begins after postoperative day 4.

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Complications

Major complications of a femoral osteotomy include the following:

  • 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 the following:

  • Deep vein thrombosis
  • Painful hardware

With regard to external fixation, complications include the following [21] :

  • Pin-site infection
  • Fracture above or below the frame and fracture through a screw hole after frame removal
  • Stiffness of adjacent joints
  • Septic arthritis if pins communicate with the joint
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