Intertrochanteric Femoral Osteotomy

Indications

• Patient selection is crucial for the success of the intertrochanteric osteotomy. Patients should be under the age of 50 years, should be motivated, and should have a clear and realistic understanding of the goal of surgery.
• Various symptomatic hip pathologies can be appropriate indications for intertrochanteric osteotomy.

Varus Osteotomy

• In avascular necrosis (AVN) of the femoral head, valgus intertrochanteric osteotomy can shift the affected part of the femoral head away from the load-bearing area of the hip joint (Fig. 1A), allowing a relatively normal surface of the femoral head to have shear contact with the acetabular dome (Fig. 1B). This can be combined with sagittal plane correction in flexion or extension.
• Hip dysplasia (Fig. 2), especially if it is mild and
• associated with coxa valgus, can be repaired with varus osteotomy (Santore et al., 2006).
• The hip joint reaction force is concentrated on a small contact area in hip dysplasia (Fig. 3A).
• Following varus osteotomy (Fig. 3B), the abductor muscle lever arm is longer, which reduces the joint reaction force. The joint contact area is larger, and muscle tension around the hip joint is lower due to proximal migration of its insertions.

• • • preoperative plan for a case of old Perthes disease. A valgus intertrochanteric osteotomy has been planned. Valgus correction was achieved and the osteotomy fixed with a 90° blade plate (Fig. 10B). In addition, the greater trochanter was transferred to improve the abductor lever arm.

      • The level of resection and the amount of angular correction required should be decided on the basis of physical and radiologic examinations.

      • The effect on leg length and the mechanical axis should also be anticipated.

        • Magnetic resonance imaging

    • In cases of AVN, it is helpful to assess the extent and site of the lesion in the femoral head before planning the osteotomy.

      • Hip arthroscopy may be considered if there is a suspicion of a loose body or labral tear.

        Surgical Anatomy

         

        P ITFALLS

        • Either the table wedge piece underneath the hip needs to be detached or a sandbag should be placed under the ischium to allow a better flexion-extension arc.

         

      • In hip dysplasia, the femoral head is usually small, and the neck is excessively anteverted and possibly short. The neck-shaft angle is increased, and the greater trochanter is displaced posteriorly. On the pelvic side, the acetabulum is shallow and deficient superiorly and anteriorly, and tends to be anteverted (Sanchez-Sotelo et al., 2002).

      • In slipped capital femoral epiphysis, the femoral head tends to be posterior, the neck is short, and the greater trochanter is overgrown.

        Controversies

        • This operation can be done when the patient is in a lateral decubitus position; however, access for the lateral fluoroscopic view will not be possible.

         

        Positioning

      • The patient is positioned supine in a traction table without traction. The leg is draped completely free to allow manipulation.

      • The contralateral leg needs to be positioned suitably to allow access of fluoroscopy equipment to obtain AP and lateral views of the hip.

         

        P ITFALLS

        • If the vastus lateralis is lifted off the intermuscular septum, the bleeding perforators can be a nuisance to trace.

         

        Portals/Exposures

      • A lateral incision is made extending 12 cm distally from the tip of greater trochanter.

      • The vastus lateralis muscle split is performed close to the lateral intermuscular septum, and the muscle is retracted anteriorly (Fig. 11).

       

      Vastus lateralis

       

       

      FIGURE 11

       

      21

       

       

      P ITFALLS

      • Care should be taken to avoid pacing the K-wire in the subtrochanteric region as the nonunion rate is significantly high.

       

      Intertrochanteric Femoral Osteotomy

       

      Procedure

      Step 1

      • A Kirschner wire (K-wire) is placed at the level of the lesser trochanter perpendicular to the shaft of the femur (Fig. 12). Fluoroscopy can be used at this stage to check the position of the lesser trochanter.

         

         

         

         

        FIGURE 12

         

        22

         

        Intertrochanteric Femoral Osteotomy

         

        Step 2

        Instrumentation/ Implantation

        • A blade plate with a 90° angle is commonly used for varus correction. Other implants, such as a dynamic condylar plate with a 95° angle, have also been used.

        • For valgus osteotomy, a 120°-angle or 110°-angle blade plate is commonly used.

         

        • A second K-wire is placed just proximal to the vastus lateralis ridge along the intended path of the blade. The position of this K-wire must be confirmed using fluoroscopy.

        • The angle of this second K-wire relative to the first varies according to the desired angle of correction and the implant used to fix the osteotomy. For example:

    • If 20° of varus correction is desired, the second K-wire is placed at 20° from the first K-wire. The angle created with the femoral shaft will be 70° (Fig. 13A).

    • If 30° of valgus correction is desired, the second K-wire is placed parallel to the first K-wire at the intended path of the blade (Fig. 13B). Thus, when using a 120°-angle blade plate implant, the 30° valgus correction will be achieved when the plate is sitting on the femoral shaft (120  90  30).

       

      70°

      Second bone cut

      First bone cut

      90°

      K-wires now parallel

      Bone wedge removed

      20° varus correction

       

       

      Second K-wire

       

      First K-wire

       

      A

      FIGURE 13

       

      23

      120°

      90°

      K-wires now parallel

      Bone wedge removed

      30° varus correction

       

       

      Intertrochanteric Femoral Osteotomy

       

      Second K-wire

       

      Second bone cut

       

      First bone

      cut

       

      First K-wire

       

       

      B

       

      FIGURE 13, cont’d

       

       

      P EARLS

      • The chisel should be introduced intermittently by backing it every few millimeters to avoid jamming.

       

      Step 3

      • The length of blade to be used is determined by measuring the length of the second K-wire in the bone with a depth gauge.

      • The chisel is inserted along the second K-wire. This should be done under fluoroscopic control until the final position of the blade is reached.

      • Rotation of the chisel should be checked carefully to allow the blade plate, when inserted, to sit on the lateral femur.

         

        P ITFALLS

        • Care should be taken to place the chisel in the proximal femur at the same angle of the anterior or posterior wedge planned to accommodate for flexion or extension correction.

           

        • A distance of at least 2 cm should be left between the entry point of the blade at the lateral femur and the osteotomy level to avoid fragmentation.

         

        Step 4

      • Femoral osteotomy is done using a saw along the first K-wire. Continuous irrigation is required to avoid thermonecrosis.

      • If flexion or extension is contemplated, a small anterior or posterior wedge is cut, respectively.

        Step 5

      • The proximal femur is displaced using a chisel and osteotome to achieve the planned correction. Using the saw, a small fragment from the medial cortex of the proximal segment is removed to achieve maximum contact at the osteotomy site. The proximal fragment is held with a bone reduction clamp.

         

        24

         

        Instrumentation/ Implantation

        • A thin saw blade should be used to perform the osteotomy so as to avoid thermonecrosis.

         

        Intertrochanteric Femoral Osteotomy

         

        • The chisel is removed and the blade plate is inserted under fluoroscopic control.

        • One 4.5-mm screw is inserted in the proximal segment when the blade has reached its final seating.

        • Using a bone clamp, the plate is seated on the femoral shaft and the rest of the screws are inserted.

        • A final check is made with fluoroscopy. Hip range of motion is also checked.

        • Figure 14 shows the repair of a dysplastic hip with a varus intertrochanteric osteotomy.

    • Preoperative planning was drawn on a radiograph of the left femur (Fig. 14A). Femoral head coverage was achieved in abduction, and the neck-shaft angle measured 150°. Therefore, 15° of correction was desirable.

 

A

B

 

15

 

135

 

15

 

 

C FIGURE 14

 

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Intertrochanteric Femoral Osteotomy

 

• The postoperative radiograph in Figure 14B shows that femoral head containment was achieved.

• Complete healing was achieved, and the metal implants were removed (Fig. 14C). Note that the intramedullary canal alignment is well maintained for future hip replacement.

 

 

 

P ITFALLS

• When displacing the proximal femoral segment, it must be kept in mind that the stem of a future total hip replacement needs to fit in the femoral canal. Therefore, minimal if any translation at the osteotomy site should be performed.

   

• Distraction at the osteotomy site should be avoided. Usually it tends to occur while performing varus osteotomy rather than with valgus osteotomy.

 

 

Controversies

• Trendelenburg gait may persist following surgery, and distal transfer of the greater trochanter may be considered to address the abductor dysfunction.

 

Postoperative Care and Expected Outcomes

• • The patient starts mobilization on the first postoperative day using crutches with toe-touch weight bearing for 6 weeks.

  • In the second 6-week period, the patient starts gradually increasing weight bearing as tolerated. Continuous hip flexion and abduction exercises should also be performed during this period. Full weight bearing can be resumed more quickly following valgus osteotomy.

  • Removal of the blade plate after 18 months is controversial but routinely done in many institutions.

  • The possible complications, such as intraoperative fracture, loss of fixation, and nonunion, are fairly uncommon (Iwase et al., 1996). The patient should be warned about postoperative leg length discrepancy, and the persistence or worsening of the lurch.

  • Overall, the results of femoral osteotomy in well-selected patients with minimal hip arthritic changes are satisfactory. Studies have shown that over 70% of patients have had a satisfactory result following varus osteotomy (Iwase et al., 1996; Pellicci et al., 1991).

  • The results of valgus osteotomy can be less predictable or at least not as successful as varus osteotomy. Studies have shown that less than 50% and 40% of patients were satisfied with the results of

 

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Intertrochanteric Femoral Osteotomy

 

valgus osteotomy for hip dysplasia and idiopathic osteoarthritis, respectively (Perlau et al., 1996).

However, valgus osteotomy for femoral neck fracture nonunion gives excellent results in achieving fracture union (Marti et al., 1989).

Evidence

D’Souza SR, Sadiq S, New AM, Northmore-Ball MD. Proximal femoral osteotomy as the primary operation for young adults who have osteoarthrosis of the hip. J Bone Joint Surg Am. 1998;80:1428–38.

 

A retrospective study of 25 hips in 23 patients with an average follow-up of 7 years. (Level III evidence)

 

Iwase T, Hasegawa Y, Kawamoto K, Iwasada S, Yamada K, Iwata H. Twenty years’ followup of intertrochanteric osteotomy for treatment of the dysplastic hip. Clin Orthop Relat Res. 1996;(331):245–55.

 

A cohort study of 110 hips in 95 patients over a mean follow-up of 20 years. (Level III evidence)

 

Lequesne M, De Seze S. False profile of the pelvis: a new radiographic incidence for the study of the hip. Its use in dysplasias and different coxopathies. Rev Rhum Mal Osteoartic. 1961;28:643–52.

Marti RK, Schuller HM, Raaymakers EL. Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br. 1989;71:782–7.

 

A cohort study of 50 patients over an average follow-up of 7.1 years. (Level III evidence)

 

Pellicci PM, Hu S, Garvin KL, Salvati EA, Wilson PD Jr. Varus rotational femoral osteotomies in adults with hip dysplasia. Clin Orthop. 1991;(272):162–6.

 

A cohort study of 56 hips in 48 patients over a mean follow-up of 12.5 years. (Level III evidence)

 

Perlau R, Wilson MG, Poss R. Isolated proximal femoral osteotomy for treatment of residua of congenital dysplasia or idiopathic osteoarthrosis of the hip: five to ten-year results. J Bone Joint Surg Am. 1996;78:1462–7.

 

A retrospective study of 34 hips in 33 patients over a mean follow-up of 6.1 years. (Level III evidence)

 

Sanchez-Sotelo J, Berry DJ, Trousdale RT, Cabanela ME. Surgical treatment of developmental dysplasia of the hip in adults: I. Nonarthroplasty options. J Am Acad Orthop Surg. 2002;10:321–33.

 

A review of non-joint replacement treatment of mild to moderate symptomatic hip dysplasia in young adults. (Level IV evidence [review article])

 

Santore RF, Turgeon TR, Phillips WF 3rd, Kantor SR. Pelvic and femoral osteotomy in the treatment of hip disease in the young adult. Instr Course Lect. 2006;55: 131–44.

 

A review article detailing the authors extensive experience in the treatment of mild to moderate hip arthritis by means of both femoral and pelvic osteotomy with detailed results. (Level IV evidence [review article])