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

Femoral head reduction osteotomy with simultaneous periacetabular osteotomy for severe femoral head deformities

Aims

The aim of this study was to describe femoral head reduction osteotomy (FHRO) and review its safety, the radiological correction which may be obtained, and the clinical results at a minimum follow-up of two years.

Methods

A total of 12 patients (12 hips) with a severe deformity of the femoral head, mainly from Perthes' disease, underwent FHRO using the surgical hip dislocation technique with an extended retinacular flap. Their mean age was 17 years (12 to 25). Radiographs were obtained before and after surgery to evaluate morphological parameters, articular congruence, and cartilage damage. Preoperative arthro-MRI was used to evaluate the condition of the cartilage and the spatial distribution of the damage. The clinical outcome was assessed using the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS).

Results

At a mean follow-up of 4.6 years (2 to 9), all osteotomies had healed unremarkably and no patient had symptomatic avascular necrosis. The mean femoral head size index changed significantly from 120% (SD 10) before surgery to 100% (SD 10) after surgery (p = 0.004). The mean femoral head sphericity index also changed significantly from 71% (SD 10) to 91% (SD 7) (p = 0.002). The mean femoral head extrusion index changed significantly from 37% (SD 17) to 9% (SD 6) (p = 0.002). The mean NAHS score improved significantly from 41 (SD 18) to 69 points (SD 9) (p = 0.002). The mean HOS score also improved significantly from 56 (SD 24) to 83 (SD 17) (p = 0.010) and the mean mHHS score improved significantly from 46 (SD 15) to 76 points (SD 13) (p = 0.004).

Conclusion

Thus far, in this series, FHRO could be considered to be a safe surgical procedure with considerable potential for correcting severe deformities of the hip and improving patient-reported outcome measures.

Morphometry and Morphology of the Fovea Capitis of the Femoral Head and its Associated Implications

BACKGROUND AND OBJECTIVE

The fovea capitis, a depression in the posteroinferior quadrant of the head of the femur, provides attachment to the ligament of the head of the femur, transmitting vessels to the head of the femur. The ligament is often disrupted, leading to avascular necrosis of the head of the femur. The morphometry and morphology of the head of the femur and fovea capitis are useful in various clinical conditions involving the hip joint. The study aims to assess the morphology and morphometry of the head of the femur and fovea capitis and to correlate these with clinical implications.

METHODS

 The study was conducted in the Department of Anatomy, Uttar Pradesh University of Medical Sciences (UPUMS), Saifai, India, using 40 femora of unknown age and sex. The morphometry was done using a digital vernier caliper, and morphological forms were observed.

RESULTS

 The mean perimeter of the femoral head was 12.3 ± 1.09 cm, and that of the fovea capitis was 4.2 ± 0.9 cm. The area of the femoral head was 48.27 ± 1.02 cm², and that of the fovea capitis was 4.84 ± 0.1 cm². The most common morphological form was oval-shaped, constituting 50%, followed by circular and triangular shapes. The least common morphological form observed was irregular-shaped.

CONCLUSION

 The information provided in this study will be of utmost use in dealing with hip joint pathologies like dysplasia and osteoarthritis, reconstructing injured ligaments of the head of the femur, proximal femur measurements, radiological interpretation, arthroscopic procedures, and other surgical interventions involving the hip joint.

Modified trochanteric triplane osteotomy for chronic moderate to severe slipped capital femoral epiphysis - a preliminary report

PURPOSE

Management of chronic moderate and severe slipped capital femoral epiphysis (SCFE) remains controversial. We propose that the modified trochanteric triplane osteotomy(MTTO) with a 1300 angled blade plate, without removal of bone wedge, is effective for addressing moderate and severe chronic SCFE.

METHODS

A retrospective review was performed on patients who underwent MTTO for moderate to severe chronic SCFE, with at least two years follow-up. Radiological outcomes assessed were osteotomy union, alpha angle, neck shaft angle, mechanical axis deviation and limb length discrepancy(LLD). Functional outcomes were assessed using modified Harris hip score, lower extremity functional scale (LEFS) and SF-36 questionnaire.

RESULTS

A total of 11 patients (13 hips) underwent MTTO for chronic SCFE, with a mean age of 12.9 ± 2.1 years. The pre-operative median modified Harris Hip Score was 73. 12 had severe slip and one had moderate slip. All the osteotomies went on to unite by two months. At an average of 37 months follow up, the mean neck shaft angle was 1290, mean alpha angle was 69.70, and mean LLD was 1.05 cm. There was significant improvement in the post-operative modified Harris hip score (p < 0.001), the median post-operative modified Harris hip score was 96, and the median LEFS was 78. One case had bone scan evidence of AVN, but did well with bisphosphonate therapy and one case had a superficial infection.

CONCLUSION

MTTO is a safe and effective option for addressing deformities in chronic moderate and severe SCFE. However, a residual proximal femoral Cam deformity persists after this procedure which may need to be treated with a simultaneous or a staged osteochondroplasty.

Is Subcapital Realignment for Slipped Capital Femoral Epiphysis a Reproducible Technique? Midterm Results

BACKGROUND

The modified Dunn procedure, which is based on the development of an extended retinacular flap containing the blood supply for the femoral head, allows anatomic reestablishment in patients with moderate to severe slipped capital femoral epiphysis (SCFE). Some controversy exists regarding the short-term to midterm risk of avascular necrosis (AVN) and other complications resulting from the surgical technique.

QUESTIONS/PURPOSES

(1) What percentage of patients treated with an extended retinacular flap during the modified Dunn procedure for SCFE with a moderate (slip angle from 30° to 60°) or severe slip (slip angle equal or greater than 60°) develop symptomatic AVN, and what percentage underwent further surgery or had other complications? (2) What femoral head-neck alignment and position parameters relative to the greater trochanter are achieved after surgery? (3) Can we identify radiographic signs of osteoarthritis at a minimum of 4 years after surgery?

METHODS

Between January 2006 and December 2018, we treated 61 patients for SCFE. During this time, we generally used the modified Dunn procedure when the slip angle was ≥ 30°. Based on this indication, the modified Dunn procedure was performed in 37 patients (41 hips) during that time period, and those patients were potentially eligible for this retrospective study. Because bilateral hips in the same patient are not statistically independent, for our analyses, we analyzed only the hip with the longer follow-up time. Of those who remained, 11% (4) were lost before the minimum study follow-up of 48 months or had incomplete datasets, leaving 89% (33) for analysis here at a median follow-up of 80 months (range 49 to 208 months). Periacetabular osteotomy or subtrochanteric rotational femoral osteotomy was added under the same anaesthesia time in 33% (11 patients). We added periacetabular osteotomy in 24% (8) when intraoperative anterior instability was present in external rotation. A femoral rotational osteotomy was added in 9% (3) when posterior instability was present in flexion and internal rotation. The mean ± standard deviation age at the time of surgery was 13 ± 1 years, and 33% (11 of 33) of patients were female. The mean slip angle was 51° ± 16º, and 15% (5) of hips had unstable slips, defined as an inability to walk with or without crutches. We documented chronic presentations in 82% (27) of patients, acute and chronic in 12% (4), and acute in 6% (2). The rate of symptomatic AVN was determined by reviewing all radiographs obtained at the latest follow-up interval. Further surgery and other complications were assessed through an electronic medical record review. Radiographic morphologic parameters were measured before surgery and at a minimum follow-up of 4 years by two senior orthopaedic surgeons. Radiographs obtained at the latest follow-up visit were also screened for signs of osteoarthritis by the same surgeons.

RESULTS

At the latest follow-up, 3% (1 patient) of patients developed symptomatic AVN and underwent further surgery and 3% (1) underwent revision surgery for screw breakage after a high-energy fall. Postoperatively, the alpha angle was restored to 39º ± 6º, the anterior head-neck offset was restored to 8 ± 3 mm, the neck-shaft angle was 136º ± 6º, and the presence of a positive Klein line decreased from 64% (21 hips) to 0% (0 hips). No patients showed radiographic signs of osteoarthritis at the minimum follow-up of 4 years.

CONCLUSION

In this series, the modified Dunn procedure in moderate and severe slips was a reproducible procedure, and few patients developed symptomatic AVN or experienced other complications. Hip morphology was restored, but a longer follow-up duration and a detailed analysis of the results from other centers is warranted to assess the possible long-term risk of progression to AVN or osteoarthritis.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

A Femoral Neck Osteotomy for the Patients with Ankylosing Spondylitis and Thoracolumbar Kyphosis Combined with Hip Flexion Contracture

OBJECTIVE

The surgical treatment of patients with ankylosing spondylitis and severe thoracolumbar kyphosis combined with hip flexion contracture is very difficult for all the surgeons. The femoral neck osteotomy (FNO) is the first step to break the ice. The evaluation of a new modified FNO method is very important to improve the curative effect.

METHODS

Five male patients with nine bone-fused hips who underwent the new femoral neck osteotomy were included from October 2021 to March 2022. The FNO was designed that the saw blade was manipulated from the lateral femoral neck base to the inferior part of the femoral head, keeping Pauwels' angle less than 30° on the coronal plane. On the transverse plane, the angle between the saw blade and the coronal plane was more than 15°. On the sagittal plane, the saw blade cut through the femoral neck. They accepted pedicle subtraction osteotomy (PSO) after FNO according to the patient' recovery. Then, 2 weeks later, the patients underwent total hip arthroplasty (THA). The visual analogue scale (VAS), Harris hip score (HHS) and passive hip flexion-extension range of motion (ROM) were used to evaluate hip function. The data were analyzed by paired t-test.

RESULTS

The average operation time and blood loss of FNO, the average interval between FNO and THA were collected. The average angle of the trunk and lower limb (ATL) was 36.33° ± 16.36° pre-FNO, 82.89° ± 13.51° post-FNO and 175.22° ± 3.42° post-THA. The average VAS scores were 0 pre-FNO, 5 ± 1.58 post-FNO and 2.6 ± 0.55 post-THA. The average HHS was 43.56 ± 1.59 preoperatively and 83.89 ± 2.21 postoperatively. The average hip extension ROM was 23.89° ± 12.69° pre-FNO, -22.67° ± 14.18° post-FNO and - 3.33° ± 2.50 post-THA°. The average hip flexion ROM was 23.89° ± 12.69° pre-FNO, 35.56° ± 12.11° post-FNO and 104.44° ± 5.27° post-THA. The differences among them were significant (p < 0.05). Only one hip (11.11%) displaced completely after FNO.

CONCLUSION

A new modified FNO was developed, which can provide osteotomy with a certain degree of stability and greater ease for performing PSO and THA.

Long-term results of valgus intertrochanteric osteotomy for partial avascular necrosis of the femoral head after femoral neck fracture in adolescents

PURPOSE

The study evaluates long-term results in patients treated by valgus intertrochanteric osteotomy (VITO) for partial avascular necrosis of the femoral head (ANFH) after fracture of the femoral neck in adolescent age. Although this method is mentioned in literature frequently, there are only few studies in the literature dealing with it in detail.

METHODS

Authors evaluated five patients at the interval of 15 to 20 years following VITO. The mean age of the patients at the time of injury was 13.6 years and at the time of VITO 16.7 years. The studied parameters included resorption of necrotic segment of femoral head, development of posttraumatic osteoarthritis and leg shortening.

RESULTS

Comparison of radiographs and MRI scans before and after VITO showed resorption of the necrotic segment of the femoral head and its remodeling in all five patients. However, two patients gradually developed slight osteoarthritic changes. In one patient, remodeling of the femoral head occurred during the first 6 years postoperatively. Subsequently, the patient developed severe osteoarthritis with marked clinical symptoms.

CONCLUSION

VITO can improve the long-term function of the hip joint in adolescents with ANFH after a femoral neck fracture, but cannot restore completely the original shape and structure of the femoral head.