Awareness and use of intertrochanteric osteotomies in current clinical practice. An international survey

Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results

PURPOSE

Using an extended retinacular flap containing the blood supply for the femoral head, proximal femur osteotomies can be performed at the neck level increasing the potential of correction of complex morphologies. The aim of this study was to analyze the safety, clinical, and radiographic results of this intra-articular surgical technique performed in skeletally mature patients with a minimum follow-up of three years.

METHODS

Fourteen symptomatic adult patients (16 hips) with a mean age of 26 years underwent FNO using surgical hip dislocation and an extended soft tissue flap. Radiographs and radial magnetic resonance imaging (MRI) were obtained before and after surgery to evaluate articular congruency, cartilage damage, and morphologic parameters. Clinical functional evaluation was done using the Nonarthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS).

RESULTS

After surgery, no avascular necrosis was observed, and all the osteotomies healed without complication. The initial neck/shaft angle (range 120 to 150°) improved in all cases to a mean value of 130° ± 4.6 (p < 0.001). In eight of nine valgus hips, the high-positioned fovea capitis changed to a normal position after surgery. The NAHS score improved from a mean of 36.5 ± 14.9 to 82.9 ± 13.9 points after surgery (p < 0.001). After surgery, the mean HOS was 87.1 ± 17.6 points, and the mean mHHS was 78.6 ± 17 points.

CONCLUSIONS

In this series, femoral neck osteotomy in the adult, although technically more demanding compared with other classic osteotomies, can be considered a safe procedure with considerable potential to correct hip deformities.

Valgus intertrochanteric osteotomy for coxa vara of Bucholz-Ogden Types II and III in patients older than 30 years

BACKGROUND

Ischemic necrosis of the proximal femur resulting in coxa vara is a severe iatrogenous complication of the treatment of developmental dysplasia of the hip (DDH). Severe relative overgrowth of the greater trochanter and reduction of the neck result in insufficiency of hip abductors. Unequal limb length causes obliquity of the pelvis, compensatory scoliosis of the lumbar spine and valgus deformity of the ipsilateral knee. The purpose of this study was to investigate the effect of valgus intertrochanteric osteotomy in patients with coxa vara older than 30 years.

METHODS

Fifteen female patients of the average age 43 years (range 31-60) with postdysplastic varus deformity of the proximal femur and shortening of affected limb of 2-4 cm were treated with valgus intertrochanteric osteotomy. None of them was operated on before. In eight cases, the varus deformity of the proximal femur was evaluated as Bucholz-Ogden Type II, in seven cases as Bucholz-Ogden Type III. The average follow-up was 10 years (range 5-20).

RESULTS

By the time of the last functional follow-up, three patients had already underwent conversion of osteotomy to total hip arthroplasty (THA), namely, 7.5, 11, and 12 years after osteotomy. All the patients evaluated the effect of osteotomy positively, including those treated later with THA. The average preoperative Harris Hip Score was 83, the postoperative one was 93.

CONCLUSIONS

Based on results, the valgus intertrochanteric osteotomy appears to be a reliable treatment for postdysplastic coxa vara in patients older than 30 years.

Operative treatment of avascular necrosis of the femoral head after proximal femur fractures in adolescents

PURPOSE

Our aim was to assess operative treatment for post-traumatic avascular necrosis of the femoral head (ANFH) in adolescents.

METHODS

Eleven patients with an average age of 17 (range 14-26) years were operated up on for ANFH after proximal femoral fractures. The average interval between injury and reconstructive surgery was four (range two to eight) years. The average follow-up of the entire cohort was 89 (range 48-132) months. Five patients with total ANFH were treated by total hip replacement (THR). Six patients with partial ANFH were treated with valgus intertrochanteric osteotomy (VITO).

RESULTS

In all patients, operation improved hip function. The average preoperative Harris Hip Score (HHS) was 70 points and average postoperative HHS was 97 points. Comparison of magnetic resonance imaging (MRI) scans before and after VITO demonstrated resorption of the necrotic segment of the femoral head and its remodelling in all six patients with partial ANFH. A complication was encountered in one patient.

CONCLUSION

Patients treated for ANFH had good medium-term outcomes after THR for total necrosis and also after VITO for partial necrosis.

Long-term results of intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip

The beneficial role of intertrochanteric varus or valgus osteotomy in the treatment of hip osteoarthrosis has been recognised since the 1920s. Even today, it has an important role to delay the need for hip replacement in younger patients. The purpose of this study was to evaluate the long-term results of intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip. Between 1980 and 1995, 52 hips with dysplastic osteoarthritis underwent an intertrochanteric varus osteotomy. All patients could be followed up after 17.8 years. Radiographic assessment included centre-edge (CE) angle of Wiberg and collodiaphyseal (CCD) angle. Dysplastic hip dislocation was classified according to Crowe. Osteoarthritis was graded according to Tönnis. Preoperative osteoarthritis was Tonnis grade 1 in 19 hips, grade 2 in 28 and grade 3 in five. Complications were also documented. Clinical evaluation included score according to Merle d'Aubigné, Harris Hip Score and range of motion. Six of 52 patients underwent total hip replacement (THR) within five years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 3 in four cases and grade 2 in one case according to Tönnis. Twenty-five of 52 patients underwent THR after an interval of five to ten years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 3 in one case and grade 2 in 24 cases according to Tönnis. Sixteen of 52 patients underwent THR after an interval of ten to 15 years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 2 in four cases and grade 1 in 12 cases according to Tönnis. In five patients the hip was functioning well after a period longer than 15 years. In all these cases osteoarthritis was grade 1 according to Tönnis. In 40.4% of patients, THR was delayed longer than ten years. The osteotomy performed well at a mean time of 9.7 years after the procedure (range 3-21). Intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip should be considered in early or mild osteoarthritic changes of the hip. Good prognosis with delay of THR of more than ten years can be expected to exceed 40%, even when indications are less than optimum.