Techniques

Osteotomy Options

 

Varus

Valgus

Extension

Flexion / Internal Rotation

Neck Lengthening

 

Varus Osteotomy / Pauwels Type I

 

Indications

 

DDH 

- improve coverage

- rarely done alone

- only if little or no acetabular dysplasia

- CE > 15 - 20o

 

Perthes 

- improve coverage

 

AVN 

- if medial head involved (unusual)

 

Coxa Valga > 135°

- lateral subluxation of head

- signs of lateral overload i.e. eccentric sourcil

- adduction contracture

 

Requirements

- spherical head 

- increased congruity in max abduction

- minimum 15o abduction

 

Contraindication 

- lateral head osteophyte

 

Technique

- subtrochanteric osteotomy

- medial shaft displacement 10 - 15 mm

- 120o Synthes locking plate with offset

 

Valgus Intertrochanteric / Pauwels Type II

 

Indications

 

1.  AVN

- to unload anterolateral head

- usually valgus flexion

 

2.  Subcapital fracture nonunion

 

3.  Severe medial OA with medial osteophytes

- capital drop osteophyte

- inferomedial femoral head osteophyte

- acts as fulcrum against acetabular osteophyte

- widens the superolateral joint surface

 

4.  Coxa vara

- congenital / developmental

- fibrous dysplasia

 

5.  Protrusio in young patient

 

6.  Fixed abduction contracture

 

Requirement

 

90° flexion & 15° adduction

 

Technique

 

Calculate osteotomy

- mostly would be aiming for neck shaft angle 145 - 150o

 

Example coxa vara

- current neck shaft angle i.e. 110o

- desired neck shaft angle i.e. 145o

- require a 25correction

 

Fixation

- use a 145o plate and screw

- place screw in centre of femoral neck and head

- thus when fixate the plate on femoral shaft, will have obtained desired correction

 

Rotation

- mark proximal and distal femur with drill holes

- allows maintenance of current rotation / correction if required

 

Osteotomy

- use 2 K wires

- usually performed at level of lesser trochanter

- insert distal wire parallel

- insert second wire at desired angle

- check with II / angle measurement devices

- may wish to insert distal steinman pin to control distal fragment

- anterior and posterior homan retractors

- osteotomy with saw

 

Close osteotomy

- apply plate

- use compression device Synthes

 

Extension Intertrochanteric Osteotomy

 

Indication

 

In association with correction in coronal plane

Anterior uncovering of femoral head in DDH

FFD / flexion contracture

 

Effect

- improved anterior covering of head

- eliminates FFD

 

Flexion / Internal Rotation Intertrochanteric Osteotomy

 

Indication

 

Severe SUFE 

 

Technique

 

Imhauser Technique