Indices Affecting Outcome of Neglected Femoral Neck Fractures After Valgus Intertrochanteric Osteotomy

Abstract

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Valgus osteotomy for nonunion and neglected neck of femur fractures

“…While the calculated wedge may be as high as 40 degrees, most authors in the recent literature have reported that a wedge of 25-30 degrees is often sufficient to produce the desired effect [11,14,15] . Even in cases where an osteotomy is not required to obtain a valgus orientation, its advisable to do so as, this may help improve the blood supply to the femoral head.…”

“…Though the presence of radiological AVN preoperatively is not a contraindication for head salvage, the reported post-valgus osteotomy AVN rates range from 10% to 40% [10,14,23] . Not all patients who develop AVN are symptomatic, and conversion rates to THA for treating aims to convert shear forces.…”

“…The angle of wedge measured for removal in the intertrochanteric region is necessary to ensure the vertical fracture plane achieves a near-physiological orientation. However, this angle may be difficult to calculate in patients with long-standing nonunion and can only be confirmed when a closed reduction is obtained on the fracture table [14] . Another complicating factor is that the neck in these patients is often resorbed on the inferior and posterior aspect, which can cause retroversion when impacting the fracture during fixation.…”

“…Marti et al [10] and Raaymakers et al [27] have shown that excessive valgus is detrimental to function ( Figure 3). A more recent study showed that > 15 degrees of excess valgus, compared to the normal hip, results in poorer functional outcome [14] . Thus, the philosophy has evolved over the years to promoting the reproduction of as normal a proximal femoral anatomy as possible (Figure 4).…”

“…The proposed biomechanical solution was to redirect these forces into compression forces via an angulation osteotomy and fixation with a blade plate device. Valgus intertrochanteric osteotomy as described by Pauwels [6] and subsequently modified by Muller [12] is still in use today, and remains a popular treatment option as it has a high success rate and corrects the common symptoms of coxa vara and associated limb length discrepancy [11][12][13][14] . Marti et al [10] helped to popularize the valgus intertrochanteric osteotomy for nonunion NOF by reporting good outcome in a long-term follow-up study.…”