Conservative Hip Surgery Case Title: Femoral Head Reduction Osteotomy
Demographics
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Age: 15 years Sex: Male BMI: 20.5
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Relevant Past Medical History
Principal pathologies: Complex deformity after Perthes disease
Previous surgical procedures: None Medication: NSAR, physical therapy Other: Non-weight bearing on crutches
History of presenting complaint: Pain with motion and during walking. Limitation of motion
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Clinical Examination
Symptoms: Pain with passive motion
Range of motion: Limited abduction, limited internal rotation in flexion and extension
Specific tests: Positive impingement test
Main disability: Pain
Scoring if available: HHS 65.7
Neurovascular evaluation: Normal neurovascular status
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Preoperative Radiological
Assessment/Imaging (Figs. 1.7
and 1.8)
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Fig. 1.7 AP pelvis radiograph with irregular flattening and extrusion of the epiphysis, no neck, high-riding trochanter, and leg shortening of 2 cm
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Fig. 1.8 MRA radial reconstruction slice showing the head deformation
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Preoperative Planning
Diagnosis: Complex deformity after Perthes disease. (Figs. 1.7 and 1.8)
Possible treatment options: Advancement of the greater trochanter; varus osteotomy (together with trochanteric advancement); valgus femoral osteotomy; shelf acetabuloplasty, Chiari pelvic osteotomy, and periacetabular osteotomy, all with trochanteric advancement; and femoral head reduction osteotomy together with relative neck lengthening and trochanteric advancement.
Chosen treatment method: Femoral head reduction with relative neck lengthening and trochanteric advancement (Fig. 1.9).
Selection of implants if applicable and rational: 3.5 mm screws from 30 mm to 70 mm length. Expected difficulties: Selection of shape and size of the head segment to be resected. A decision whether additional periacetabular osteotomy
for joint stability is needed.
Strategies to overcome difficulties: Intraoperative drawing of the segment cuts on the cartilage surface. More recently, simulation of the cuts with 3D-CT models (Fig. 1.9).
Central column
Trochanteric osteotomy
Medial column
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Lateral column
Fig. 1.9 Head reduction osteotomy plan
Templating: 3D-CT modeling is now possible, but was not available for this case.
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Surgical Note
Patient’s position: Lateral decubitus. Free leg draping. Skin preparation and draping should allow change to supine decubitus without the need for redraping.
Type of anesthesia: General anesthesia because repositioning may be necessary.
Surgical approach: Surgical dislocation approach as described in “Case Title: Surgical Hip Dislocation as the First Step for Revision of Instability from Arthroscopy” (Ganz R, Leunig M) (Chapter 1.5.).
Main steps: The surgical dislocation approach is extended by a subperiosteal dissection of the posterolateral retinaculum containing the necessary vessels for a sufficient perfusion of the epiphysis; the flap length from insertion at the head-neck junction to the level of the lesser trochanter is necessary to avoid overstretching of the vessels during manipulations for the osteotomy. The first step is a piece meal resection of the stable trochanter down to the level of the posterior neck applying a strictly subperiosteal execution. All external rotators are part of this flap. More proximally, the periosteum of the neck is longitudinally incised at the anterior border of the retinaculum. Both parts together are further dissected from the bone toward the posterior neck using a sharp periosteal elevator. Execution of the posteromedial flap is not necessary when dealing with a head reduction osteotomy because the medial 1/3 of the head remains connected with the femoral neck and shaft. Special care is taken to preserve Weitbrecht’s ligament with the medial branch of the medial femoral circumflex artery, running on its surface and supplying this part of the epiphysis.
Reconstruction techniques: Based on MRI and
CT, one gets already a conception of the central resection area. The stable medial part must have a neck column which is strong enough to resist
adverse forces during manipulation and should allow refixation of the mobile lateral 1/3 of the head. The cuts are to be oriented in a way to keep the posterolateral retinaculum attached to the mobile fragment and to protect Weitbrecht’s ligament with the blood supply to the medial portion of the head. Most frequently the middle part is resected with parallel cuts; however, the resected part can also be triangular with an anterior basis, always considering that the remaining cut surfaces become suitable. On the top view of the dislocated head, the cuts are mapped before executed. Execution is performed alternating with a small saw blade and straight osteotomes. The lateral fragment should include a neck portion allowing fixation against the stable part with 2–3 2.5 mm screws. Relative neck lengthening as needed in such cases is already the result of taking down the stable part of the greater trochanter; however, impingement-free motion may be tested again and optimized if needed. The stability of the joint is tested manually and with external rotation; it may lead to the decision for an additional periacetabular osteotomy. The posterolateral retinaculum is reattached only approximately and without creating tension; to allow it, the piriformis tendon may be released. Distal advancement of the greater trochanter is facilitated with a release of its long tendon along the anterior border of the fragment. Trochanteric fixation is performed with two 3.5 screws [16–18] (Figs. 1.10 and 1.11).
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Intraoperative Challenges
Challenges and solutions: The first challenge is the decision about the size of the segment to be resected and the direction of the cuts. Mapping on top of the head is very helpful. Re-cutting can easily compensate a somewhat smaller segment. For optimal matching, the mobile lateral part may have to be advanced, rotated, and even angulated. Rarely fine - tuning of the cartilage contour is necessary. More recently, simulation with individual plastic models produced with 3D scan is available. In the majority of cases, secondary
deformation of the acetabulum and the smaller head size necessitate an additional periacetabular osteotomy to restabilize the new head. In the presented case, however, this was not necessary.
Unanticipated problems and solution: Unexpected problems regarding this procedure may have to do with scarce experience. The operation should not be undertaken based on textbook knowledge or looking to videos only. Training is recommended in a center where such surgery is performed. Without optimal preoperative imaging, e.g., high-quality MRI focused on the diseased hip only and/or 3D computer tomography image decisions may not be based on realistic expectations. Nevertheless, occasionally intraoperative findings of cartilage quality or surface contour may not be as anticipated and compel to change to another procedure. For an intraoperative change of procedure, it is advantageous to have discussed such a possibility with patient and parents before surgery.
Thorough description of decision making, including the reason for the final decision: Occasionally, the medial contour of the head is deformed like a spike, and the lateral portion is large and round but extruded. In such a situation, resection of the medial spike, relative neck lengthening, and periacetabular osteotomy represent a better and less demanding operation. Similarly, when in a double-head deformity, the medial 2/3 are round and covered with good cartilage, and the lateral bump is small; it may be resected; again relative neck lengthening and periacetabular osteotomy may complete the correction. A relatively rare situation is when resection of a part of the head is not necessary, and periacetabular osteotomy together with relative neck lengthening is sufficient. Finally, it may happen that the lateral 2/3rds of the head are severely involved, but the medial contour is good. In such a condition, a valgus femoral osteotomy with or without periacetabular osteotomy may be considered, while an isolated varus femoral osteotomy is quite never indicated, and a simple debridement of the joint is a
salvage procedure with very little chance for success.
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Postoperative Radiographs
(Figs. 1.10 and 1.11)
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Fig. 1.10 AP radiograph of the pelvis five years after surgery with good containment and large joint space
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Fig. 1.11 Lateral view after five years with congruent joint lines and large joint space
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Postoperative Management
Chemoprophylaxis and anticoagulant treatment period: Routine antibiosis is given for 24 h. Prophylaxis for DVT is not given up to the age of 18, provided there are no risk factors.
Gait/limb loading until full loading: Patients are starting ambulation the first or second day after surgery using elbow crutches. Allowed is toe-touch loading for six weeks when a first control radiography is performed. Thereafter, a stepwise increase of loading is allowed: first ten kg for two weeks and twenty kg for two weeks. After a second radiographic control at twelve weeks, walking on one crutch in the opposite hand is allowed and has to be kept until abductor force has regained an M5.
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Follow-Up and Complications
Report of postoperative complications and their management (i.e., recurrent dislocation): Follow-up of the presented case was according to the abovementioned recommendations; no complications were recorded. At five years the patient had occasionally and little pain. Except for slight reduction of abduction, the range of motion was free and symmetrical. In our series of 37 cases since 2001, there is no necrosis but one fracture of the stable medial neck column which was successfully treated with screw fixation along the axis of the neck and a pelvic plaster for six weeks. Another paper about twenty hips reports one necrosis [19]. The 10-year results of our first eleven cases showed improved containment and sphericity and reduced pain [20].
Scoring if available: The presented case reached 92 HHS points at five years.
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Discussion
Advantages of the applied method: Femoral head reduction osteotomy is a procedure to treat severe femoral head deformity, as seen in Perthes disease, at the level of deformity. It is often com-
bined with relative neck lengthening and containment surgery of the acetabulum.
Disadvantages of the method: The technique is rather demanding and requires detailed knowledge of the blood supply and advanced experience with intracapsular hip surgery.
Alternative evidence-based techniques for the case: All alternative techniques have an indirect impact, be it reorientation of the proximal femur or augmentation and reorientation alone of the acetabulum.
Why is the chosen technique better for this case? Besides the direct approach to the femoral head deformity, it allows treating the secondary deformation like high-riding trochanter, absent femoral neck, and adaptive flattening of the acetabular fossa.
Indications and contraindications for your technique: The general indication for this technique is still under debate. So far the experience is best with patients between the age of nine and twenty years before. Before nine years of age, there is a concern of undesired effect on the growth plates; after the age of twenty years, joint degeneration may reduce the positive balance between expected result and expenditure of surgery.
Learning curve and how to manage complications: With a background of experience with the modern techniques of surgical hip preservation and with a strict period of supervision, the learning curve is steep regarding the technique and the management of complications.
Level of evidence concerning the superiority of this method against others: Although only 10-year results are available with a small number of cases and the combination of procedures was not homogeneous, a tendency becomes visible whereupon results are best when head reduction is combined with relative lengthening of the neck and periacetabular osteotomy; however, in selected cases additional periacetabular osteotomy may not be necessary. In general, it is obvious that congruency and containment of the hips are better with the proposed technique when compared with indirect approaches.
