Femoral Osteotomy Treatment & Management
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.
Alternatives to femoral osteotomy in patients with arthritis include :
Total hip replacement: The age indication for hip arthroplasty continues to broaden for patients with coxarthritis. This is in a large part the result of 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.
Distraction arthroplasty hip joint: This has been successful in children with Perthes disease and may have a role in adults.
Before performing a femoral osteotomy:
Review all information from history, physical examination, and imaging studies.
Correlate the radiographic measured degree of deformity with the clinical examination findings. Optimize the patient’s range of motion and function; do not simply treat based on the radiograph findings.
If using a blade plate, determine the optimal position for the blade in the femoral neck based on radiographic findings.
Plan the level of osteotomy.
Consider best approach with regard to skin condition.
Have correct instrumentation available to remove old hardware.
Obtain medical clearance and achieve patient optimization prior to surgery.
Involve the patient and the family in the decision-making process.
Provide the patient with realistic expectations from the surgery.
The following items should be available in the room when performing a femoral osteotomy: the patient’s radiographs, a goniometer, Steinman pins to judge rotation, C-arm fluoroscopy, and a broken hardware removal set. The operating table should be a fracture table or Jackson flat table with a bump under the ipsilateral buttock.
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 such that when the deformity is corrected the pins will be parallel.
Place guide wire for the blade plate into the femoral neck and head in the predetermined ideal location. The seating chisel is advanced 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 (due to 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 10-15 degrees of varus correction.
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.
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 allows for simultaneous lengthening through osteotomy. However, the frame may be uncomfortable, a risk of pin tract infection exists, and a second surgery is required for frame removal.
External fixation is typically reserved for low intertrochanteric or subtrochanteric osteotomies. When using external fixation, 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 1 to 2 pins are placed above the level of the lesser trochanter. Three to 4 pins are placed in the shaft of the femur for stability.
If using Ilizarov-type rings, then one ring or ring block is attached to each segment to mimic the deformity. A percutaneous osteotomy is made, and the rings are manipulated to place the femur into the desired alignment. If the rings truly mimic the deformity, then the reduction is obtained by making the rings parallel. The rings are then fixed to one another. The same correction can be obtained using a monolateral fixator. Again the frame is mounted in the deformed position and then acutely or gradually moved into the corrected position.
After a femoral osteotomy:
Drains are removed postoperative day 1.
Partial weight bearing is typically allowed immediately.
Wound care is routine.
Showering and pin care protocols are surgeon specific. Typically showering begins after postoperative day 4.
The follow-up to a femoral osteotomy includes the following:
Office visit at 2 weeks to remove sutures
Regular monthly visits with radiographs until bony union is observed
A shoe lift may be indicated for limb length inequality, or a later limb-lengthening procedure may be planned if indicated.
Major complications of a femoral osteotomy include 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 deep vein thrombosis and painful hardware. With regard to external fixation, complications include pin site infection; fracture above or below the frame and fracture through a screw hole after frame removal, stiffness of adjacent joints, and septic arthritis if pins communicate with the joint.
Outcome and Prognosis
When proximal femoral osteotomy is used for the correction of congenital and acquired deformities and repair of hip fracture nonunion, results have been favorable. Hip range of motion, gait, pain, leg-length discrepancy, and patient satisfaction are improved. If arthritis develops, then future joint replacement is often facilitated. Simultaneous femoral osteotomy and total hip arthroplasty is a technically demanding procedure that has yielded acceptable results for complex hip reconstruction with deformity.
With regard to the use of proximal femoral osteotomy in the non-deformed hip with osteoarthritis, long-term follow-up reveals that many patients go on to require total hip arthroplasty. Some authors conclude that a place still exists for osteotomy in the treatment of hip osteoarthritis in younger patients. However, many have reported on the increased difficulty and higher complication rates associated with total hip arthroplasty performed in hips that have undergone previous intertrochanteric osteotomy procedures aimed at alleviating arthritic pain.
Future and Controversies
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.[16, 17, 18] 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.
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