Subtrochanteric osteotomy for femoral mal-torsion through a surgical dislocation approach

Abstract

Missed torsional femur deformities may contribute to reasons for failure after open and more likely arthroscopic hip preservation surgery. A number of surgical approaches have been described for addressing torsion abnormalities. This report describes a subtrochanteric osteotomy technique in a consecutive series of patients with complex hip pathologies, for which intertrochanteric osteotomy is not suitable and precise derotation is required. Subtrochanteric derotation was performed, always in combination with a surgical hip dislocation, in accordance with the authors’ preferred technique. Before osteotomy, a localized decortication was executed. Application of a 4.5-mm broad or narrow plate was undertaken with dynamic compression of the osteotomy. Twenty-eight consecutive subtrochanteric derotational osteotomies were performed in 26 patients. Twenty-one females and five males were treated at an average age of 21.4 years (range, 12–43). Underlying diagnoses included dysplasia, arthrogryposis, cerebral palsy, Down’s syndrome, instability and impingement. The decision to perform derotation was for antetorsion over 20° or less than 0° (retrotorsion). Patients were followed clinically and radiographically till final follow-up. All patients went on to successful osteotomy union. There were two initial failures: one delayed union prompting revision fixation in a chronic smoker and one plate failure due to self-accelerated weight-bearing in a patient status post successful contralateral derotational osteotomy. Rotational deformity of the femur must be considered in the patient undergoing hip preservation surgery. This technique of subtrochanteric derotational osteotomy, with adjunctive surgical hip dislocation, is applicable and reproducible in the setting of complex hip pathologies. Level of evidence: IV, case series.

Femoral Derotation Osteotomy in Adults for Version Abnormalities

“…A subtrochanteric derotation femoral osteotomy may also be performed by plating, but it requires a much more invasive approach. 40 The advantage of the described technique is that it allows for a much less invasive approach, lessening surgical morbidity and theoretically a lower chance of infection. In addition, the vastus lateralis is not dissected from the femur, maintaining more of the periosteal blood supply to enhance bone union.…”

“…Kamath et al 40 reported 28 rotational femoral osteotomies in 26 patients, 93% for excessive femoral anteversion. Clinical outcomes were not reported.…”

Hip contact stress and femoral neck retroversion: a biomechanical study to evaluate implication of femoroacetabular impingement

“…Derotational osteotomies have been used to correct femoral retrotorsion and have been shown to decrease pain associated with impingement. The premise used in our model was that if derotation can correct retroversion, a rotational osteotomy should be able to produce retroversion [ 30 ]. Matsuda et al [ 27 ] corrected femoral retroversion in their case report by doing bilateral proximal femoral derotational osteotomies.…”

“…A 300-lb load was chosen as an approximation of the joint reaction force one might experience in rising from or lowering into a chair [ 24 ]. Proximal femoral and subtrochanteric osteotomies have been used to correct retroversion/retrotorsion in FAI [ 27 , 30 , 31 ]. Thus, a subtrochanteric osteotomy was chosen for this model as it was easily reproducible, retroversion could be calibrated and the osteotomy could be rigidly fixed.…”

Femoroacetabular Impingement: What the Surgeon Wants to Know

“…18 Intraoperatively it is possible to test for full range of motion (ROM) before performing acetabular osteoplasty or to opt for a subtrochanteric derotation osteotomy if needed. 59 Surgical hip dislocation also allows for a full labrum reconstruction using fascia lata, hamstrings tendons, or ligamentum teres. 26,60 At the end of the procedure the capsule should be partially closed to avoid intra-articular increased pressure from cancellous bone bleeding.…”